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1. Review and process health plan appeals in compliance with Commercial and Medicaid guidelines.
2. Collaborate with medical directors on case reviews and clinical decision-making.
3. Analyze medical documentation to ensure appropriate resolution of appeals.
4. Provide clear, accurate, and timely communication regarding case outcomes.
5. Maintain compliance with regulatory requirements and organizational policies.
6. Support continuous improvement in appeals processes and workflows.

1. Active Registered Nurse (RN) license.
2. Minimum of 2 years of health plan appeals experience.
3. Prior experience with Commercial and Medicaid payor systems.
4. Strong analytical and clinical review skills.
5. Excellent communication and collaboration abilities.

• Experience working directly with medical directors or physician reviewers.
• Familiarity with managed care processes and regulatory requirements.

1. Active RN license required.
2. Additional certifications in case management or utilization review are a plus.

Education: High School

Certification: Certified Registered Central Service Technician