RN Clinical Appeals Nurse

Job Summary

A company is looking for a Clinical Appeals Nurse to manage clinical denials and appeals related to medical necessity and level of care.

Key Responsibilities

• Manage and communicate clinical denials and appeals from third-party payers and government entities
• Evaluate and ensure accuracy of clinical appeal letters and track appeal outcomes
• Report denial trends and participate in audit reviews as needed

Required Qualifications

• RN license in good standing, maintained throughout employment
• Minimum of two years of Utilization Review/Case Management experience in a managed care or hospital setting
• Knowledge of regulatory standards, compliance requirements, and medical terminology
• Familiarity with Medicare and Commercial admission regulations
• Experience with the denial and appeal process preferred