Clinical Appeals Nurse

Details

Join our dedicated team at HBiz where we strive to provide outstanding care and service excellence. We

are currently seeking a highly skilled Clinical Appeals Nurse to play a crucial role in managing medical

denials by providing clinical expertise in the appeals process. This position is ideal for those who excel in

analytical thinking and have a strong background in clinical practice and health information management.

Key Responsibilities:

• Review and analyze clinical documentation, utilization records, and insurance denial rationales to formulate well-constructed appeal cases.
• Engage in the appeals process for denied claims, ensuring that all appeals are submitted in a timely manner according to regulatory and insurer-specific requirements.
• Utilize clinical experience and knowledge in accordance with established Milliman or Interqual guidelines to substantiate medical necessity and appropriate le...