**Resp & Qualifications**

**PURPOSE:**
The Clinical Appeals Nurse completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The Clinical Appeals Nurse utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Commercial line of business in order to formulate a professional response to the appeal request. We are looking for an experienced clinician to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities.

**ESSENTIAL FUNCTIONS:**

+ Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stake holders and any other initiators. Responds...