Clinical Appeals RN

The Clinical Appeals RN is responsible for attending appeal hearings, defending MassHealth prior authorization decisions, and performing pre-service/prior authorization clinical coverage review of services. Works closely with managers and peers. Primary responsibilities include representing MassHealth at appeal hearings, defending prior authorization decisions using program-specific regulations and medical necessity guidelines, determining appropriateness of inpatient and outpatient services, identifying solutions to non-standard requests, and participating in regular meetings to ensure operational efficiency. Requires an unrestricted RN license in Massachusetts, 3+ years of managed care and/or clinical experience, and residence in Massachusetts. Preferred qualifications include prior-authorization, utilization management, appeals, and Medicare/Medicaid experience. Minimum 10% travel within MA. Hourly pay range $28.94-$51.83.