Opportunity Description
Job Title: Appeals Clinical ReviewerJob Description
The Appeals Utilization Review Nurse reviews and evaluates member and provider appeals related to medical necessity determinations, authorization decisions, and claims outcomes. This role applies clinical expertise, evidence-based guidelines, regulatory requirements, and internal policies to ensure fair, timely, and compliant appeal determinations. The nurse collaborates closely with Medical Directors, providers, claims teams, and utilization management staff to support high-quality patient care while promoting appropriate utilization of healthcare services. This position offers the opportunity to transition to a permanent role and is performed fully remotely.
Responsibilities
+ Review and evaluate member and provider appeals related to medical necessity determinations, authorization decisions, and claims outcomes.
+ Apply clinical expertise and evidence-based guidelines to ensure accurate, fair, and consistent...
The Appeals Utilization Review Nurse reviews and evaluates member and provider appeals related to medical necessity determinations, authorization decisions, and claims outcomes. This role applies clinical expertise, evidence-based guidelines, regulatory requirements, and internal policies to ensure fair, timely, and compliant appeal determinations. The nurse collaborates closely with Medical Directors, providers, claims teams, and utilization management staff to support high-quality patient care while promoting appropriate utilization of healthcare services. This position offers the opportunity to transition to a permanent role and is performed fully remotely.
Responsibilities
+ Review and evaluate member and provider appeals related to medical necessity determinations, authorization decisions, and claims outcomes.
+ Apply clinical expertise and evidence-based guidelines to ensure accurate, fair, and consistent...
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