Pennsylvania Licensed RN Clinical Appeals Specialist

Key responsibilities: Manage assigned clinical appeals, ensuring all documentation is complete and accurate Apply clinical nursing knowledge and utilization management principles to support case classification and appeal handling Coordinate and document matched-specialty reviews and prepare clear written correspondence to stakeholders

Required qualifications: Bachelor of Science in Nursing required Active, unrestricted Pennsylvania RN license required Minimum of five years of clinical nursing experience or equivalent healthcare experience Experience in utilization management, clinical appeals, or related managed care operations Knowledge of NCQA standards and state and federal appeal regulations