California Licensed RN Clinical Reviewer

Job Summary

A company is looking for an RN Clinical Review Clinician - Appeals.

Key Responsibilities

• Perform clinical reviews to resolve and process appeals by analyzing medical records and clinical data
• Ensure timely review and processing of appeals in compliance with State, Federal, and NCQA standards
• Communicate with members, providers, and other departments regarding appeals requests and generate appropriate resolution communications

Required Qualifications

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