Clinical Appeals Nurse (Remote)

Position Overview

The Clinical Appeals Nurse completes research, evaluation, and analysis of member and provider disputes regarding adverse coverage decisions. Utilizing clinical expertise and knowledge of all applicable State and Federal regulations, the role formulates professional responses to appeal requests. This is a remote position within the greater Baltimore metropolitan area with periodic in-person meetings at a CareFirst location.

Key Responsibilities

• Investigate, interpret, and analyze appeals and reconsideration requests from multiple sources, responding with detailed, original letters that adhere to corporate policy and State/Federal regulations.
• Organize appeal cases by compiling clinical, contractual, medical policy, and claims information; prepare and communicate case decisions following physician review.
• Evaluate appeal requests using expert nursing knowledge, collaborating with Independent Review Organizations and contracted Panel Physicians to determine if adverse decisions are appropriate.
• Maintain a continuously expanding knowledge base of current medical practices, procedures, and regulatory requirements.

Required Qualifications

• High School Diploma or GED
• RN – Registered Nurse with valid State Licensure and/or Compact State Licensure upon hire
• 2 years’ medical-surgical (or similar clinical) experience OR 3 years’ experience in a mental health/psychiatric setting
• Demonstrated understanding of medical terminology, regulatory/accreditation requirements, and the appeals process

Preferred Qualifications

• 2 years’ experience in Medical Review, Utilization Management, or Case Management at a managed care organization
• BSN/MSN Degree
• CCM – Certified Case Manager and LNCC – Legal Nurse Consultant Certified preferred

Benefits & Perks

• Compensation: $66,960 - $132,990 (salary range based on experience, internal equity, and location)
• Comprehensive benefits package including various incentive programs and 401k contribution plans
• Opportunity to work remotely with periodic in-person meetings and training sessions