Maine Licensed Clinical Appeals Professional

A company is looking for a Clinical Appeals Professional (Remote within Maine).

Key Responsibilities Review and interpret medical records to assess clinical appropriateness and medical necessity Coordinate and manage appeal cases throughout the review lifecycle, including hearings representation Conduct outreach to healthcare providers to obtain necessary medical records and support clinical discussions

Required Qualifications Active, unrestricted RN, Social Worker, or applicable clinical license in good standing Bachelor's degree in Nursing, Social Work, Social Services, or a related field Experience in utilization management, clinical appeals, case management, or care coordination Ability to present and defend clinical cases during consultations and hearings Understanding of clinical best practices and evidence-based standards in alignment with regulations