RN Clinical Review Clinician in Durham, NC

A company is looking for a Clinical Review Clinician - Appeals. Key Responsibilities Performs clinical reviews to resolve and process appeals by analyzing medical records and clinical data Ensures timely review and processing of appeals in compliance with State, Federal, and NCQA standards Communicates with members, providers, and other departments regarding appeal requests and generates resolution communications Required Qualifications Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing 2 - 4 years of related experience Active RN license or other relevant state licensure required Knowledge of NCQA, Medicare, and Medicaid regulations preferred Utilization management experience preferred