RN Appeals & Utilization Review Specialist

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

Job summary

MedStar Health is seeking a Nurse Appeals Specialist to facilitate and manage medical appeals and assist with clinical claims issues. You will investigate and resolve member and practitioner appeals within plan regulatory and accreditation timeframes, and perform ER review activities.

The role requires a Bachelor’s degree in Nursing, 5–7 years of diverse clinical experience with utilization review, and an active Maryland or DC nursing license.

Qualifications

• Bachelor's degree in Nursing is required.
• 5–7 years of diverse clinical experience.
• 1–2 years of utilization review experience.
• Prior experience in appeals preferred.

Responsibilities

• Facilitates and manages medical appeals and assists with clinically oriented claims issues.
• Abstracts medical records and approves payment of services per policies.
• Prepares and reviews appeal summaries for Medical Director review.
• Reviews ER denials for Prudent Layperson Criteria and medical necessity.
• Documents all appeals and ER reviews accurately in the clinical software system.
• Collaborates with Medical Directors and other departments on complex cases.

Skills

Utilization review

InterQual knowledge

Medical records abstraction

Nursing licensure

Microsoft Office

Education

Bachelor's degree in Nursing

Tools

Microsoft Office

Job description

MedStar Health is seeking a Nurse Appeals Specialist to facilitate and manage medical appeals and assist with clinical claims issues. You will investigate and resolve member and practitioner appeals within plan regulatory and accreditation timeframes, and perform ER review activities.

The role requires a Bachelor’s degree in Nursing, 5–7 years of diverse clinical experience with utilization review, and an active Maryland or DC nursing license.