The Clinical Appeals Nurse Analyst completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. Completes the Internal appeal and grievance process through investigating, interpreting and analyzing clinical information. Appeals Process Investigates, interprets, and analyzes written appeals and grievances (and reconsiderations), and subsequent correspondence and telephone calls from applicants, subscribers, attorneys, group administrators and any other initiators of appeals and grievances, including in-house staff. Communication of Appeals Process Organizes the Internal appeal and grievance cases for physician review by compiling clinical, contractual, medical policy and claims information along with corporate and appellant correspondence. Investigates and analyzes the information and formulates recommendations for disposition. Required: Registered Nurse licensed to practice in Maryland with a minimum of 3-5 years medical-surgical or similar clinical experience. A minimum of 2 years experience in Medical Review, Utilization Management or Case Management
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