Appeals RN: Utilization Review & Medical Appeals

MedStar Health; United States; On-site; USD 89,000 - 163,000; Full time

Job summary

MedStar Health in Maryland seeks a nurse-focused professional to manage medical appeals and assist with clinically oriented claims issues. You will investigate and resolve member and practitioner appeals within plan regulatory timeframes and conduct ER review activities.

The role requires a Bachelor of Science in Nursing, active Maryland or DC license, and 5–7 years of clinical experience including utilization review.

Qualifications

• Bachelor's degree in Nursing is required.
• 5-7 years of diverse clinical experience.
• 1-2 years of utilization review experience required.
• Experience with appeals is preferred.
• Active and unrestricted nursing license in Maryland or DC.

Responsibilities

• Abstracts medical records and approves services per policy.
• Conducts initial medical record review for clinical appeals.
• Reviews ER denials using Prudent Layperson Criteria.
• Documents all appeals and outcomes in the clinical software system.
• Collaborates with Medical Directors on denials and grievances.
• Participates in multidisciplinary quality and service improvement teams.

Skills

Clinical appeals management

Interqual knowledge

Utilization review

Nursing knowledge

Attention to detail

Education

Bachelor's degree in Nursing

Tools

Microsoft Office

Job description

MedStar Health in Maryland seeks a nurse-focused professional to manage medical appeals and assist with clinically oriented claims issues. You will investigate and resolve member and practitioner appeals within plan regulatory timeframes and conduct ER review activities.

The role requires a Bachelor of Science in Nursing, active Maryland or DC license, and 5–7 years of clinical experience including utilization review.