Position Summary: Responsible for the timely review and resolution of clinical appeals submitted by providers and members across all lines of business. Communicates appeal determinations in accordance with regulatory requirements and serves as a clinical resource to support non-clinical staff with administrative denials and coding-related appeals. Maintains accurate tracking of appeals through logs, databases, and reporting tools.

Education: Graduate of an accredited school of nursing required; BSN preferred.

Licensure/Certification: Current Registered Nurse (RN) license in the State of Maryland required.

Experience: Minimum of three (3) years of acute care nursing experience required. Prior experience within a health insurance or payer environment strongly preferred, including case management, utilization management, appeals, or claims processing. Experience participating in quality improvement initiatives is a plus.

Position Summary: Responsible for the timely review and resolution of clinical appeals submitted by providers and members across all lines of business. Communicates appeal determinations in accordance with regulatory requirements and serves as a clinical resource to support non-clinical staff with administrative denials and coding-related appeals. Maintains accurate tracking of appeals through logs, databases, and reporting tools.

Education: Graduate of an accredited school of nursing required; BSN preferred.

Licensure/Certification: Current Registered Nurse (RN) license in the State of Maryland required.

Experience: Minimum of three (3) years of acute care nursing experience required. Prior experience within a health insurance or payer environment strongly preferred, including case management, utilization management, appeals, or claims processing. Experience participating in quality improvement initiatives is a plus.