RN Clinical Appeals Nurse

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