Clinical Appeal Nurse

About the Role BHPS provides Utilization Management (UM) services to its clients, ensuring high-quality, clinically sound decision‑making. The Clinical Appeal and Grievance Nurse is responsible for conducting daily clinical and benefit reviews in a quality‑focused, production‑driven environment. The position reports directly to the Clinical Appeal Manager. Note: This job description is not intended to be an exhaustive list of duties. Responsibilities may evolve or change at any time, with or without notice. This is a remote role. Primary Responsibilities Independently review and analyze pre- and post-service medical necessity and benefit appeals, post‑service clinical claim disputes, and quality of care grievances. Utilize member‑specific benefit information, nationally recognized clinical criteria, and internal policies and procedures across multiple care disciplines, including, but not limited to, Inpatient Acute, Post Acute, Outpatient, Specialty Pharmaceutical, and Durable Medical Equipment. Prepare and present cases to internal Medical Directors and external Independent Review Organizations (IROs) for timely and accurate decisions. Ensure strict adherence to Appeals and Utilization Management (UM) processes and regulatory and accreditation requirements from intake through case closure. Prioritize caseload and other assigned duties to meet clinical accuracy expectations and turnaround time requirements. Accurately enter case details in medical management platform. Collaborate with team members and other departments to achieve exceptional results and drive continuous improvement. Essential Qualifications Active and unrestricted RN or LPN license; must maintain licensure throughout employment. Minimum of 5 years’ experience in Clinical Appeals and Grievances within a managed care or payor setting. Minimum of 5 years’ clinical experience across various care settings (Inpatient Acute, SNF/LTAC/ARU, Outpatient, DME, Complex Care). Strong understanding of UM/Appeals regulatory guidelines including URAC, NCQA, and ERISA. Proficiency in Clinical Appeals, Utilization Review, and Grievance processes including benefit interpretation, contract language, and medical policy application. Excellent written and verbal communication skills. Proficient in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint). Ability to work independently with exceptional accountability. Adaptability to a fast‑paced and evolving environment. Preferred experience in a Third‑Party Administrator (TPA) setting. Preferred coding certification. #J-18808-Ljbffr Brighton Health Plan Solutions, LLC