State Licensed Clinical Review Clinician

Job Summary

A company is looking for a Clinical Review Clinician - Appeals.

Key Responsibilities

• Perform clinical reviews to resolve and process appeals by analyzing medical records and clinical data
• Prepare case reviews for Medical Directors and ensure timely processing of appeals in accordance with standards
• Communicate with members, providers, and other departments regarding appeal requests and generate resolution communications

Required Qualifications

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
• 2 - 4 years of related experience in appeals, denials, and utilization management
• Active nursing license or relevant clinical licensure (LPN, LVN, RN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist)
• Knowledge of NCQA, Medicare, and Medicaid regulations preferred
• Familiarity with utilization management processes preferred