Appeals RN: Utilization Review & Medical Policy Liaison

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

Job summary

MedStar Health seeks an experienced Appeals Nurse to manage medical appeals, reviews, and denials in Maryland. You will abstract clinical information, confirm payments per NCQA Maryland COMAR, and coordinate with Medical Directors to ensure timely resolution.

Responsibilities include initial medical record reviews for clinical and ER appeals, drafting responses, and maintaining accurate documentation in the clinical software system.

Qualifications

• Bachelor's degree in Nursing is required.
• 5-7 years of diverse clinical experience; familiarity with InterQual criteria.
• 1-2 years of utilization review experience required.
• Prior appeals experience preferred.

Responsibilities

• Manage and document medical appeals within regulatory timelines.
• Abstract and analyze medical records to approve payments per policies.
• Prepare case summaries for Medical Director review.
• Review ER appeals for Prudent Layperson Criteria and medical necessity.
• Coordinate with Medical Directors and participate in quality teams.
• Prepare drafts of denial reasons for MD review.
• Maintain accurate clinical software records.

Skills

Medical records literacy

Clinical analysis

Communication

Independent work

Time management

Team collaboration

Microsoft Office

Education

Bachelor's degree in Nursing

Tools

InterQual criteria

Clinical software

EMR systems

Job description

MedStar Health seeks an experienced Appeals Nurse to manage medical appeals, reviews, and denials in Maryland. You will abstract clinical information, confirm payments per NCQA Maryland COMAR, and coordinate with Medical Directors to ensure timely resolution.

Responsibilities include initial medical record reviews for clinical and ER appeals, drafting responses, and maintaining accurate documentation in the clinical software system.