Appeals Nurse Consultant (Remote)
Core
Review and resolve clinical appeals by applying clinical judgment and regulatory knowledge to member and provider issues.
Role type
Senior IC clinical nurse consultant (appeals)
Builds
Clinical resolution outcomes for health plan members and providers
Domain
Health insurance / Utilization management
Required skills
Clinical judgment, regulatory knowledge, documentation review, data interpretation, coordination with clinicians, UM/MPO/Coding/Behavioral Health appeals expertise
Preferred skills
Appeals experience, Managed Care experience, Utilization Review experience, computer proficiency, multitasking
Technologies
Multiple clinical systems
Responsibilities
Review and resolve clinical appeals, interpret clinical records against criteria and policies, coordinate clinical resolution with internal/external support, support expedited UM, MPO, Coding, or Behavioral Health appeals
Seniority
Mid-level, hands-on IC