Appeals Nurse

Job Title: Clinical - Appeals Nurse



Contract Duration: 7 months, with possibility of extension



Location: Florida



Schedule: M-F; 9am to 6pm (Saturdays- same as weekday schedule)



Interview: Microsoft Teams Camera On

Position Overview:

Typical Day in the Role:

• Receive assignments electronically via company applications and excel sheets, emails are also sometimes used for case communication.
• Review appeal requests, medical records, and apply applicable medical necessity criteria.
• Write up the appeal clinical review and forward to MD for review and final determination.
• Receive the case back post MD review for clinical closure and route to coordinator for case closure.
• 4-8 complete cases per day.
• Ability to work remotely and self-directed to keep oneself at pace.
• Able to use clinical knowledge and experience to visualize the appeal request and get better understanding of clinical picture.

Years of experience required: At least 3 years in a clinical setting followed by at least 1 year experience in managed care/ utilization management setting such as prior authorization clinical reviewer; appeals clinical reviewer a plus/preferred.

Disqualifiers: Less than 1 year or no managed care / utilization management experience.

Additional qualities to look for: Experience using InterQual criteria application, Also, candidate who in addition to clinical physical health experience has experience in clinical mental health care.

Education/Certification:

• Required : Nursing certification/degree

Licensure

• Required: RN FL Licensure Required

Top 3 Must-Have Hard Skills:

1.Clinical utilization management experience clinical reviews

2. InterQual criteria application

3. Able to work independently