Clinical Appeals Nurse - RN - ONLY W2 New

Candidates must be located in Maryland, Washington, DC, or Northern Virginia

Title: Clinical Appeals Nurse

Location: Owings Mills, MD 21117 OR DMV (Remote)

Duration: 6 Months Contract

Job Description:

Terms of Employment

• Contract, 6 Months (Possible Extension)
• This position is primarily remote. However, candidates must be located in Maryland, Washington, DC, or Northern Virginia and able to commute to Owings Mills or Baltimore, MD for required on-site training during the initial weeks of the assignment.

Overview & Responsibilities

• Join nTech in supporting our client, a prominent health insurance provider, in a vital Clinical Appeals Nurse role. You will be instrumental in upholding a significant Maryland state mandate focused on timely healthcare appeals and grievance processing. This position requires meticulous attention to detail and the ability to navigate complex clinical information systems to ensure all medical records are obtained within stringent five-day deadlines. If you are an RN with strong medical records review experience and a commitment to compliance, we want to hear from you!

Responsibilities:

• Triage incoming appeals and grievances related to a Maryland state risk mandate.
• Conduct thorough searches for existing clinical records across various company platforms, including SIR and GuidingCare.
• When records are not internally available, initiate requests to providers via fax within a strict five-day timeframe.
• Determine and gather necessary clinical documentation (e.g., CT scans, surgery reports) for appeals.
• Utilize your nursing expertise to assess clinical information and attach all relevant documentation to a SharePoint database.
• Follow up with provider offices and hospitals to obtain additional medical information as needed.
• Collaborate with internal teams to ensure accurate and timely processing in compliance with state regulations.
• Maintain comprehensive documentation of all case activities.
• Participate actively in client-provided training on systems and processes.

Required Qualifications

• Active Registered Nurse (RN) license in Maryland or a recognized compact state, with the ability to practice in Maryland.
• Must be currently located in the DC/Maryland/Virginia (DMV) area and available for initial on-site training in Owings Mills or Baltimore, MD.
• A minimum of two (2) years of clinical nursing experience, preferably in direct patient care.
• A minimum of two (2) years of experience in medical records review, utilization management, or clinical records analysis, including the ability to interpret medical documents.
• Strong organizational skills with high attention to detail, especially for managing timelines and regulatory needs.
• Proficiency with digital systems for record-keeping, case management, and documentation (SharePoint experience is a plus).

Preferred Qualifications

• Prior experience with GuidingCare, Facets, or Nasco systems.
• Experience with document repository systems like SIR.
• Background as a surgical nurse or experience in a surgical setting.
• Previous experience handling appeals and grievances within a healthcare insurance environment.

Sincerely,

Preetam Raj

Lead Technical Recruiter

nTech Workforce Inc.

D: 891-811-9010 EXT: 726

E: 670re@zi1afzh8.com

preetam(at)ntechworkforce(dot)com