Clinical Appeal Nurse

Job description

About the Role BHPS provides Utilization Management (UM) services to its clients, ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting daily clinical and benefit reviews in a quality-focused, production-driven environment. The position reports directly to the Clinical Appeal Manager. Note: This job description is not intended to be an exhaustive list of duties. Responsibilities may evolve or change at any time, with or without notice. This is a remote role. Primary Responsibilities: - Independently review and analyze pre and post service medical necessity and benefit appeals, post-service clinical claim disputes, and quality of care grievances. - Utilize member-specific benefit information, nationally recognized clinical criteria, and internal policies and procedures across multiple care disciplines, including, but not limited to, Inpatient Acute, Post Acute, Outpatient, Specialty Pharmaceutical, and Durable Medical Equipment - Prepare and present cases to internal Medical Directors and external Independent Review Organizations (IROs) for timely and accurate decisions - Ensure strict adherence to Appeals and...