Utilization Review Medical Appeals Nurse - USRN

Conduct clinical reviews to resolve medical appeals by analyzing medical records and data to determine medical necessity in line with company policies, NCQA standards, and Medicaid regulations. Prepare case reviews for Medical Directors, ensure timely appeal processing and responses, communicate with providers and facilities, and generate member/provider resolution reporting. Independently handle non-routine appeals using sound judgment and maintain organized appeal files with recommendations for medical review.