RN Utilization & Medical Appeals Specialist

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

Job summary

MedStar Health in Maryland seeks an experienced nurse to manage medical appeals, review clinical information, and prepare summaries for Medical Director review. The role includes ER review activities and adherence to NCQA Maryland COMAR and MedStar Family Choice policies.

The ideal candidate has an active Maryland nursing license, 5–7 years of clinical experience, and 1–2 years of utilization review experience, with prior appeals exposure preferred.

Qualifications

• Active and Unrestricted Nursing License in Maryland required.
• 5-7 years of diverse clinical experience with industry criteria such as interqual.
• 1-2 years utilization review experience required.
• Prior experience in appeals preferred.

Responsibilities

• Abstracts medical records and analyzes clinical information and approves payment of services per policy.
• Initial medical record review for all clinical appeals and prepare case summaries.
• Review ER denials against Prudent Layperson Criteria and medical necessity; make recommendations.
• Coordinate with Medical Directors on denials, adverse determinations, or grievances.
• Document all appeals and ER reviews in the clinical software system.
• Prepare drafts of denial reasons for MD review per policy.

Education

Bachelor's degree in Nursing

Job description

MedStar Health in Maryland seeks an experienced nurse to manage medical appeals, review clinical information, and prepare summaries for Medical Director review. The role includes ER review activities and adherence to NCQA Maryland COMAR and MedStar Family Choice policies.

The ideal candidate has an active Maryland nursing license, 5–7 years of clinical experience, and 1–2 years of utilization review experience, with prior appeals exposure preferred.