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The RoleThe Clinical Appeals Nurse Reviewer facilitates, coordinates, and responds to provider appeals for denied services utilizing extensive clinical, regulatory, business, and coding knowledge. Collaborates with the Physician Review Units, Medical & Payment Policy Departments, Provider Service, Member Service and Claims Area to research and resolve provider claims appeals.

The TeamAs an integral part of the Clinical Appeals team, the Appeals Nurse Reviewer will serve as a liaison and business expert for claims appeals. This role works collaboratively with Provider Service, Claims, Network Management, Physician Review, and Medical and Payment Policy teams.

Key Responsibilities:

+ Review appeals utilizing sound clinical judgement, medical policy, payment policy guidelines, pricing files, contractual obligations, and billing practices, all to appropriately adjudicate provi...