RN-Clinical Appeals

Under supervision of the Director of Case Management, the Clinical Appeals Nurse, reviews and appeals for reconsideration of medical services that may have been denied, either in part, or in whole, during the initial claims determination phase. Denial of payment may be based on insufficient medical record documentation to support the level of care, billing/coding disputes, utilization review, and/or determination that the treatment rendered is not Medically Necessary.

ESSENTIAL JOB FUNCTIONS

Every effort has been made to make this job description as complete as possible. However, it in no way states or implies that these are the only duties the incumbent will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position.

• Reviews records and determines potential for appeal on denied claims.

• Drafts appeal...