California RN Clinical Review

Job Summary

A company is looking for a Clinical Review Clinician - Appeals.

Key Responsibilities

• Performs clinical reviews to resolve and process appeals by analyzing medical records and clinical data for medical necessity
• Prepares case reviews for Medical Directors and ensures timely processing of appeals in accordance with standards
• Communicates with members, providers, and departments regarding appeal requests and generates resolution communications

Required Qualifications, Training, and Education

• California RN license required
• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
• 2 - 4 years of related experience preferred
• Knowledge of NCQA, Medicare, and Medicaid regulations preferred
• Knowledge of utilization management processes preferred