Clinical Appeals Nurse
CareSource(1 month ago)
About this role
The Clinical Appeals Nurse adjudicates clinical appeals and participates in state hearings to ensure decisions comply with regulatory, contractual, and clinical standards. The role operates within the health plan’s clinical governance framework and partners with medical leadership and internal teams to manage complex case review and external review processes.
Required Skills
- Clinical Review
- Appeals Processing
- Medical Records
- Documentation
- Regulatory Compliance
- Clinical Judgment
- Communication
- Time Management
- Decision Making
- Customer Service
+2 more
Qualifications
- Associate's Degree
- Registered Nurse (RN)
- Multi-State RN (Preferred)
- MCG Certification
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