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Loma Linda University Faculty Medical Group

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Appeals Nurse RN - Community Health Choice
The Appeals Nurse RN will assist the Appeals Manager and the Medical Director in the review of medical records submitted for appeals by providers due to adverse determination. Utilize Milliman Care Guidelines and Medical Affairs departmental policies for medical necessity and level of care determination. Utilize 3M Coding and reimbursement guideline for DRG assignment. Provides written response of the outcome of the appeals finding to the appealing provider. Assists in the ongoing development and maintenance of a database for tracking, trending and reporting appeals cases. Qualifications Registered Nurse, current Texas License One year of experience utilizing evidence based criteria in medical reviews in Utilization Management or Appeals required.


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