The Appeals Nurse Consultant plays a key role in resolving clinical complaints and appeals by reviewing medical records and applying clinical guidelines for Utilization Management group. This RN must be licensed in the state that they reside, with strong experience in utilization review, coding, and managed care. Key Responsibilities. Administers review and resolution of clinical complaints and appeals. Interprets data obtained from clinical records to apply appropriate clinical criteria and policies in compliance with regulatory and accreditation requirements for members and providers. Coordinates clinical resolutions with internal and external support areas. Remote Work Expectations. This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications. Active, unrestricted RN license in your state of residence . years Utilization Management or Utilization Review experience . year(s) of experience demonstrating knowledge of clinical and medical policy, Milliman Care Guidelines (MCG), Inter. Qual or other medically appropriate clinical guidelines, applicable State regulatory requirements, including the ability to easily access and interpret these guidelines . years clinical nursing experience, with 1-3 years managed care experience in Utilization Review, Medical Claims Review, or other specific program experience as needed or equivalent experience . year(s) of experience demonstrating knowledge of International Classification of Diseases (ICD-9), Current Procedural Terminology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Preferred Qualifications. Multistate/compact licensure privileges . year(s) of Appeals experience in Utilization Management. Education Associate's degree in nursing (RN) required, BSN preferred. Anticipated Weekly Hours 40 Time Type. Full time. Pay Range. The typical pay range for this role is:$60,522.00 - $129,615.00