RN Clinical Review Clinician

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

Ensures timely review and response to appeals in accordance with State, Federal, and NCQA standards

Communicates with members, providers, and other departments regarding appeals requests

Required Qualifications, Training, and Education

Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing

2 - 4 years of related experience

Knowledge of NCQA, Medicare, and Medicaid regulations preferred

RN, LPN, LVN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist credentials required

Experience with utilization management processes preferred