Remote Clinical Appeals Nurse | Health Plan Denials Expert

CareFirst; United States; Hybrid; USD 67.000 - 134.000; Vollzeit

Zusammenfassung

CareFirst seeks an experienced Clinical Appeals Nurse to research, analyze, and respond to member and provider disputes regarding adverse coverage decisions. The role uses regulatory knowledge to craft professional responses for Commercial lines.

The position is remote from within the greater Baltimore area with periodic on-site meetings for training and coordination. RN licensure and 3 years of relevant experience are required; certifications are a plus.

Qualifikationen

• Bachelor's in Nursing or equivalent with required RN licensure.
• 3 years of clinically related experience in medical review or utilization.
• Experience with appeals processes and regulatory requirements is preferred.

Aufgaben

• Investigate, interpret, and analyze written appeals from various sources.
• Organize cases for physician review and communicate final decisions with explanations.
• Collaborate with regulatory bodies and external reviewers as needed.
• Maintain up-to-date knowledge of medical practices and procedures.

Kenntnisse

Medical terminology

Regulatory knowledge

Communication skills

Analytical thinking

Customer service

Ausbildung

Bachelor's Degree in Nursing

Tools

Microsoft Office

Jobbeschreibung

CareFirst seeks an experienced Clinical Appeals Nurse to research, analyze, and respond to member and provider disputes regarding adverse coverage decisions. The role uses regulatory knowledge to craft professional responses for Commercial lines.

The position is remote from within the greater Baltimore area with periodic on-site meetings for training and coordination. RN licensure and 3 years of relevant experience are required; certifications are a plus.