Serving as a clinical subject matter expert, the full-time State Licensed Clinical Nurse Specialist will perform complex clinical reviews, manage appeals and claims-related cases, and collaborate across various operational areas in a remote setting. Key responsibilities Conduct complex clinical reviews for pre-service, concurrent, and post-service cases requiring advanced nursing judgment Review and provide recommendations for standard and expedited appeals, ensuring compliance with medical necessity criteria and regulatory requirements Analyze trends in clinical escalations and claims, partnering with cross-functional teams to identify issues and recommend process improvements Required qualifications Registered Nurse (RN) with a current, unrestricted license Minimum of 5 years of clinical nursing experience, including complex medical record reviews At least 2 years of utilization management or closely related managed-care experience Working knowledge of CMS guidelines and medical necessity review processes Experience with appeals, claims review, and clinical escalations
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