Position: Clinical Appeals Nurse (Nevada License)Client: Large Payer ClientLocation: 100% RemoteLength: ASAP-10/30/2026
Job DescriptionThe Clinical Appeals Nurse is responsible for the completion of clinical appeals and state hearings from all states.
Essential Functions:Responsible for the completion of clinical appeals and state hearings from all statesReview and complete all provider clinical appeals within required timeframesReview and complete member clinical appeals within required timeframesReview all information necessary to prepare State Hearing packetsCommunicate with state agencies and internal departments to prepare for State HearingsAttend assigned State Hearing and complete all required compliancesComplete required compliances for Administrative Hearing decisionsApply CareSource Medical Policy and Milliman guidelines when processing clinical appealsIssue notification letters to providers and membersIssue administrative denials appropriatelyRefer denials based on medical necessity to medical directorMaintain hardcopy documentation, Facets documentation and appeals database documentation at 90-95% accuracy ratesConduct monthly, quarterly, and ad hoc appeals reportingCollaborate with the Quality Improvement and Clinical Operations Team Lead to prepare all requests for Independent External ReviewEnsure compliance with regulatory and accrediting requirementsPerform any other job duties as requested
Education and Experience:RN License in Nevada required, compact license preferredAssociates Degree or equivalent years of relevant experience requiredManaged care, appeals, and Medicaid experience preferredUtilization review experience is strongly preferred
Competencies, Knowledge and Skills:Intermediate proficiency with Microsoft Office products and FacetsKnowledge of NCQA, URAC, OAC, and MDCH regulationsStrong written and oral communication skillsAbility to work independently and within a team environmentCritical listening and thinking skillsProper grammar usageTime management skillsProper phone etiquetteCustomer Service orientedDecision making/problem solving skillsFamiliarity of healthcare fieldKnowledge of MedicaidFlexibilityChange resiliency
Licensure and Certification:Current, unrestricted Nevada RN license as a Registered Nurse (RN) is required.