Appeals and Grievance Registered Nurse II – TLRA Clinical Appeals

Job Description

Summary:
The Clinical Appeals Nurse manages and communicates denials and appeals from third-party payers regarding medical necessity and level of care. Acting as a liaison, the nurse reviews cases based on guidelines like Milliman Care Guidelines and InterQual, determining appeal viability and managing the process. Responsibilities include analyzing denial rationales, ensuring compliance with Medicare guidelines, and drafting appeal letters. The nurse collaborates with healthcare teams to identify denial causes and reports trends to stakeholders.

Requirements:
Associate’s Degree in Nursing and an active RN License in the state of employment.

Work Type:
Full Time