Clinical Appeals Nurse

Terms of Employment
W2 Contract-to-Hire, 8 Months
This position is fully remote.
Candidates must be based in Maryland, Washington, DC, Virginia, West Virginia, Pennsylvania, Delaware, New Jersey, New York, North Carolina, Florida, or Texas.
Candidates must possess a Registered Nurse (RN) licensure (or a licensure from a Compact Nursing State).

Overview & Responsibilities
Our client, a leading health insurance provider, is seeking a Clinical Appeals Nurse to join their team. These nurses will play a pivotal role in ensuring compliance by managing the appeals and grievances process, triaging cases, and coordinating necessary actions. The position involves:
Reviewing and analyzing appeals and grievances received from various business units.
Ordering medical records for grievances within the required five-day timeframe.
Determining necessary clinical documentation for appeals such as CT scans, surgeries, or other medical procedures.
Utilizing nursing expertise to assess clinical information and attach relevant documentation to a SharePoint system.
Following up with providers or hospitals to request additional medical information as needed.
Collaborating with internal teams to ensure timely and accurate grievance processing in compliance with Maryland state regulations.
Maintaining thorough documentation of all activities related to appeals and grievances.
Participating in training provided by internal nursing and IT teams to understand the process and system workflows.

Required Skills & Experience
Active Registered Nurse (RN) license in Maryland or a compact state.
A minimum of 2 years of clinical nursing experience in direct patient care.
A minimum of 2 years of experience in medical records review, including the ability to interpret medical documents and assess clinical needs.
Strong organizational skills and attention to detail to manage timelines and regulatory requirements.
Proficiency in working within digital systems for record-keeping and case management.

Preferred Skills & Experience
Experience with GuidingCare, Facets, or Nasco systems.
Background as a surgical nurse or in a surgical setting.
Prior experience in handling appeals and grievances in a healthcare or insurance environment.