Nurse, Clinical Appeals

Jobs via Dice; Baltimore (MD); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading company is seeking a Clinical Appeals Specialist to manage member and provider disputes. The role involves research and analysis of appeals, responding professionally, and ensuring compliance with medical regulations. Ideal candidates will have a nursing background and strong analytical skills.

Qualifications

• 2 years experience in Medical Review, Utilization Management or Case Management preferred.
• 2+ years clinical experience or 3+ years in mental health/psychiatric settings.

Responsibilities

• Investigates, interprets, and analyzes written appeals from multiple sources.
• Organizes appeal cases for physician review.
• Collaborates with review organizations and physicians.

Skills

Communication

Analytical

Problem Solving

Education

BSN/MSN Degree

High School Diploma

Tools

Microsoft Office

Job description

Join to apply for the Nurse, Clinical Appeals role at Jobs via Dice.

Dice is the leading career destination for tech experts at every stage of their careers. Our client, TalTeam, is seeking the following. Apply via Dice today!

Job Title: Health Services - Nurse, Clinical Appeals

Duration of the project: 33 Weeks (7 months)

Location: Baltimore, MD - Remote - DMV or WV

Preferred Qualifications

• 2 years experience in Medical Review, Utilization Management or Case Management at CareFirst BlueCross BlueShield, or similar Managed Care organization or hospital preferred.
• BSN/MSN Degree

Role Description

The Clinical Appeals Specialist completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The specialist utilizes clinical skills and knowledge of applicable State and Federal rules to formulate responses to appeal requests.

Essential Functions

1. Investigates, interprets, and analyzes written appeals from multiple sources. Responds with professional, compliant letters.
2. Organizes appeal cases for physician review. Compiles relevant information and communicates final decisions to members and providers.
3. Investigates and analyzes appeal requests. Collaborates with review organizations and physicians to ensure appropriate decisions.
4. Maintains knowledge of current medical practices and regulations.

Qualifications

• High School Diploma required; BSN/MSN preferred.
• 2+ years clinical experience or 3+ years in mental health/psychiatric settings.

Additional Skills

• Knowledge of medical terminology and regulatory requirements.
• Excellent communication, analytical, and problem-solving skills.
• Proficient in Microsoft Office.
• RN licensure required; CCM and LNCC certifications preferred.

Additional Information

Seniority level: Entry level

Employment type: Full-time

Job function: Health Care Provider