Also referred to as: Grievance and Appeals Resolution Nurse
Requirements and Responsibilities

Appeal Resolution Nurse conducts the medical review activities needed to resolve and process clinical appeals and claims. Reviews applicable medical records and assesses clinical data to investigate and resolve disputes over the medical necessity for services, approvals, pre-certifications, or other cases. Being an Appeal Resolution Nurse understands and interprets applicable medical terminology, clinical procedures, regulations and policies. Documents cases according to guidelines and standard procedures. Additionally, Appeal Resolution Nurse prepares the documentation required for further medical review, hearings, and different appeal processes. Typically requires a bachelor's degree in nursing or equivalent. Requires a Registered Nurse (RN) license. Typically reports to a manager. The Appeal Resolution Nurse work is generally independent and collaborative in nature. Contributes to moderately complex aspects of a project. To be an Appeal Resolution Nurse typically requires 4 -7 years of related experience.

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