State Licensed Appeals Clinician

Job Summary

A company is looking for an Appeals Clinician I to utilize clinical expertise in resolving member and provider appeals.

Key Responsibilities

• Apply nursing expertise to ensure compliance with medical policies and guidelines in appeal decisions
• Conduct clinical appeal reviews in accordance with member benefits and provider contracts
• Consult with physician advisers for clinically appropriate determinations and educate non-clinical staff on clinical cases

Required Qualifications

• Bachelor's Degree in Nursing or a related field
• 3 years of experience in a clinical setting, health insurance, or case management
• Current licensure or certification in a relevant health or human services discipline
• Experience in direct clinical care, with a preference for psychiatric RN or Masters in Behavioral Health for behavioral health appeals
• Registered nurse (RN) license in Oregon, Washington, Idaho, or Utah