Accepting Applications
Full-time
Remote
LinkedIn
Posted 1 month, 1 week ago
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0 applications
Job Description
**Job title**
Clinical Appeals Nurse (RN)
**Location**
Remote
**Job type**
8 months contract with possible extension
**Role Overview**
* We are seeking experienced and detail\-oriented Registered Nurses to join a high\-performing Clinical Appeals team. This role offers the opportunity to leverage your clinical expertise in reviewing complex healthcare cases, evaluating medical necessity, and ensuring compliance with Medicare guidelines, clinical coverage criteria, and regulatory requirements.
**Key Responsibilities**
* Review and evaluate complex clinical appeals and grievances.
* Apply clinical coverage criteria, medical policies, and regulatory guidelines to determine medical necessity.
* Analyze medical records, supporting documentation, and service requests.
* Conduct preservice appeal reviews and prepare comprehensive clinical summaries.
* Present findings and recommendations to physician committees and leadership teams when required.
* Collaborate with internal departments, providers, and external stakeholders throughout the appeals process.
* Ensure compliance with Medicare, NCQA, corporate medical policies, and applicable state and federal regulations.
* Identify trends, risks, and process improvement opportunities.
* Document case determinations accurately and within required turnaround times.
* Provide clinical consultation and support to non\-clinical team members.
**Required Qualifications**
* Active Registered Nurse (RN) license.
* 3 5 years of clinical nursing experience.
* Medicare and/or Medicare Advantage experience.
* Strong knowledge of clinical coverage criteria and application of criteria to healthcare service requests.
* Experience reviewing medical records and making clinical determinations.
* Ability to collect, analyze, and interpret complex clinical documentation.
* Excellent written communication and documentation skills.
* Strong organizational and time\-management abilities.
**Preferred Qualifications**
* Utilization Management (UM) experience.
* Clinical appeals experience.
* Experience with Care Radius or similar healthcare management platforms.
* Experience preparing and presenting clinical findings to leadership or review committees.
**Prescreening questions**
: Do you have Clinical appeals experience?