Registered Nurse Clinical Appeals Specialist

A company is looking for a Registered Nurse - Clinical Appeals & Denials Specialist.

Key Responsibilities

Manage clinical denials and analyze medical necessity denials for resolution

Draft and submit medical necessity determinations based on clinical documentation review

Identify denial patterns and escalate potential risks to stakeholders

Required Qualifications

Registered Nurse (RN) educational background

2-3 years of combined clinical and utilization management experience with managed health care plans

3 years of experience in health care revenue cycle or clinic operations

Experience in utilization management, including Clinical Appeals and Grievances

Intermediate knowledge of Microsoft Office (Excel, Word, Outlook)