Job Title: Clinical Appeals Nurse
Location: OFFSITE
Type: Contract
Compensation: $44.50
Contractor Work Model: Remote
Licenses/Certifications:
Required: RN - Registered Nurse, State Licensure and/or Compact State Licensure
Preferred: CCM - Certified Case Manager, LNCC - Legal Nurse Consultant Certified
Position Summary:
TheClinical Appeals Nurse is responsible for investigating and evaluating member and provider disputes regarding adverse determinations and coverage decisions. This role involves clinical review, regulatory compliance, and written case documentation for appeals. The nurse leverages expert clinical knowledge along with applicable federal and state regulations governing the appeals process across commercial lines of business to ensure accurate, timely, and compliant responses.
Key Responsibilities:
Investigate, interpret, and evaluate written appeals and reconsideration requests from members, providers, legal representatives, and internal stakeholders.
Respond with clear, clinically informed, and regulatory-compliant decisions through technical and detailed correspondence.
Maintain consistency with organizational policies while adhering to all applicable regulatory mandates.
Compile relevant clinical records, benefit information, policies, and correspondence for physician reviewer evaluation.
Formulate clinical recommendations and prepare written summaries for physician review.
Communicate appeal outcomes and external appeal rights to members and providers in a clear and timely manner.
Use clinical nursing expertise to assess the appropriateness of adverse decisions for both medical and behavioral health conditions.
Review and apply internal medical policies and ensure adherence to federal/state regulatory and accreditation requirements.
Coordinate with Independent Review Organizations and external physician consultants to support appeal decisions.
Respond to inquiries from regulatory bodies, including Centers for Medicare & Medicaid Services (CMS), as needed.
Qualifications:
Education: