Responsible for the timely review and resolution of clinical appeals, the full-time Maryland Licensed Appeals Nurse will work remotely to communicate appeal determinations, support non-clinical staff with administrative denials, and maintain accurate tracking of appeals through various tools.
Key responsibilities Review and resolve clinical appeals submitted by providers and members across all lines of business Communicate appeal determinations in accordance with regulatory requirements Serve as a clinical resource for non-clinical staff regarding administrative denials and coding-related appeals Required qualifications Current Registered Nurse (RN) license in the State of Maryland Graduate of an accredited school of nursing; BSN preferred Minimum of three (3) years of acute care nursing experience Prior experience in a health insurance or payer setting preferred Experience with quality improvement initiatives is a plus