100% REMOTE opportunity for a Clinical Appeals Specialist. The selected candidate will be accountable for supporting multiple departments in performing functions related to appeals and grievance reporting. The Clinical Appeals Specialist completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The Clinical Appeals Specialist utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Commercial and Government Programs lines of business in order to formulate a professional response to the appeal request.

This position is a contract to permanent opportunity with our client, a major healthcare payor in the Maryland area. Although this position is 100% remote, we are seeking candidates that reside AND hold an active RN (Registered Nurse) Certificate in one of the following states: Wash DC, MD, VA, WV, NC, PA, DE, NY, NJ, TX, FL.

Required Skills

- High School Diploma is required
- RN certification is required within one of the following approved states: Wash DC, MD, VA, WV, NC, PA, DE, NY, NJ, TX, FL.
- Minimum of 2 years of Clinical Nurse background. Big Plus coming from behavior, mental health, medical-surgical or psychiatric setting.
- Medical Records review background consider a BIG PLUS
- Previous experience providing in-depth summary and medical plan document interpretation is required.
- Experience with one or more is a plus: SharePoint, Nasco, Facets, GuidingCare/HealthEdge.