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
• Ensures timely review and response to appeals in accordance with State, Federal, and NCQA standards
• Communicates with members, providers, and other departments regarding appeals requests

Required Qualifications, Training, and Education

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