Clinical Appeals RN - Remote - M-F Working Alternating Saturdays

Role Overview

The Clinical Appeals RN provides expertise in clinical appeals and grievances by analyzing, reviewing, and evaluating cases, and acts as a Clinical Interface Liaison to resolve issues concerning members, benefits, and program definitions.

Primary Responsibilities

• Review medical records and verify if requested services meet criteria.
• Review pre-service appeals for clinical eligibility for coverage as prescribed by plan benefits.
• Review and interpret plan language and coordinate reviews with the Medical Director.
• Utilize clinical guidelines and criteria, and accurately document determinations.
• Adhere to all confidentiality regulations and agreements.
• Work Monday through Friday with alternating Saturdays and mandatory overtime as needed.

Required Qualifications

• Active, unrestricted RN license in the state of residence.
• 2 years of clinical experience as an RN, including in an acute, inpatient hospital setting.
• Proficiency in Microsoft Office, Word, Outlook, and Internet applications.
• Availability to work required schedule in your time zone.

Preferred Qualifications

• Bachelor of Science in Nursing.
• 1 year of experience using MCG and/or Medicare criteria.
• 1 year of Utilization Management, pre-authorization, concurrent review, or appeals experience.