Nurse Reviewer Appeals and Hearings- Remote

Summary

We are seeking a talented individual for a Nurse Reviewer Appeals and Hearings role to coordinate and perform all appeal-related duties, including analyzing and responding appropriately to provider appeals; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; preparing case files and case summaries for hearings; and participating in virtual and on-site hearings. 

Your role in our mission

• Reviews provider appeals and redeterminations using approved clinical and coding guidelines, and documents appeal determinations clearly and concisely.
• Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards.
• Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director.
• Assists management with training new reviewers, including daily monitoring, mentoring, feedback, and education.
• Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification.
• Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
  Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce that meets client needs.

What we're looking for

• Active, unrestricted RN license in the United States and primary home residency; active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
• 5+ years of clinical experience or 5+ years of medical record coding experience required.
• 3+ years of utilization review experience or claims auditing required.
• Working knowledge of the appeals and hearings process.
• Experience using MCG or InterQual criteria preferred.
• Excellent written communication skills, including the ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations.
• Excellent oral communication skills, with particular emphasis on verbally presenting case summaries and decisions.
• Ability to multi-task in a fast-paced production environment. 

What you should expect in this role

• Remote within the U.S.
• Up to 25% travel

Applications for this posting will be accepted until July 30, 2026.