RN Clinical Review Clinician

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
• Prepares case reviews for Medical Directors and ensures timely response to appeals in accordance with standards
• Communicates with members and providers regarding appeals and collaborates with teams to enhance clinical appeals processes

Required Qualifications, Training, and Education

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