Remote Appeals RN: Medicare Medical Necessity Expert
WPS Health Solutions
- Remote job
WPS Health Solutions is seeking an Appeals Nurse to review medical records and appeals for Medicare services. This role involves evaluating clinical necessity, preparing compelling rationales, and coordinating with the appeals team to resolve determinations in a timely manner. The ideal candidate holds an ASN/BSN, an active RN license, and 1+ year of clinical experience, with strong communication and detail orientation. #J-18808-Ljbffr WPS Health Solutions
- WPS Health Solutions is hiring an Appeals Nurse to review medical records and claims for first-level Medicare appeal cases to determine medical necessity and compliance with coverage guidelines... .... Qualifications include an active RN license (state of practice), 1+ years...Remote jobMedical
- ...Healthfirst is seeking an Appeals & Grievances Clinical Specialist to lead clinical case... ...federal and state regulations. The role may be remote or on-site at NYC or Lake Mary locations... ..., and prepare submissions for review by Medical Directors and external appeals, while...Remote workMedical
- ...nursing judgment to analyze medical records, documentation,... ...Registered Nurse (RN) license Strong clinical... ...populations Remote work - enjoy the convenience... ...to determine medical necessity, appropriateness, quality... ..., reason codes, and appeal rights in compliance with...Remote workMedicalFull timeTemporary workWork at officeWork from home
- ...nursing judgment to analyze medical records, documentation,... ...Registered Nurse (RN) license Strong clinical... ...populations Remote work - enjoy the convenience... ...eligibility, medical necessity, appropriateness, and level... ..., reason codes, and appeal rights in accordance...Remote workMedicalFull timeTemporary workWork at office
- WPS Health Solutions in Columbus, OH, is seeking an Appeals Nurse to review medical records and Medicare claims for first-level appeals to determine medical necessity and coverage alignment. The role collaborates with Appeals Examiners to prepare timely redeterminations...Remote jobMedical
- ...Pharmacy Careers is seeking a highly qualified Remote Appeals Pharmacist to support fair access to medications and advocate for members' needs. You will review clinical data, apply guidelines, and craft written rationales for appeal outcomes. The role supports flexible...Remote workMedicalFlexible hours
- ...Clinical Review Specialist to provide remote clinical review support. You will evaluate medical necessity, level of care, and payer... .... The role requires an active RN license (compact preferred), 3-... ...2+ years in Utilization Review/Appeals. Strong documentation and Epic...Remote jobMedicalRelief
- WPS Health Solutions is seeking an Appeals Nurse to review medical records and claims for first-level Medicare redeterminations to determine medical necessity and coverage alignment. You will collaborate... ...policies. The role requires an RN license, ASN/BSN, and 1+ year...Remote jobMedical
- ...Role Snapshot The Appeals Nurse examines medical records and claims information... ...necessary and meet Medicare coverage guidelines... .... The Appeals RN works in collaboration... ...Location We are open to remote work in the following... ...the clinical necessity of services and make...Remote workMedicalContract workTemporary workFor contractorsLocal areaImmediate start
- ...dedicated Registered Nurse (RN) Clinical Denials and Appeals to join the team. This role will be Full-Time Remote, Monday-Friday (8-Hours per... ...Member Health: offering medical, dental and vision coverage... ...ability to assess medical necessity and documentation support...Remote workMedicalFull timeMonday to FridayFlexible hours
- ...Medicare Advantage Appeals RN - 162609 Clearwater: Park Place | Business and Administrative | Full... ...excellence. Summary: Conducts medical necessity and quality-of-care reviews for... ...often will this team member be working remotely? Hybrid - 1 day in office, 4 days...Remote workMedicalFull timeWork at officeMonday to FridayShift workWeekend work
$72k - $81k
MedWatch is seeking a Registered Nurse Case Manager to manage an individual caseload remotely, coordinating services, reviewing treatment plans for medical necessity, and maintaining active communication with the health care team. This home-based role emphasizes URAC-aligned...Remote jobMedicalWork from home$100 - $150 per hour
...Management / Case Management leader (RN/Physician-advisor) Type:... ...00–$150/hour Location: Remote Role Responsibilities... .... Evaluate AI-generated medical necessity determinations and clinical review... ...review requests, and denial appeals. Coordinate with clinical...Remote workMedicalContract workSummer workNight shift- ...currently seeking a highly motivated RN Clinical Appeals & Utilization Review for an... ...Appeals & Utilization Review Location: Remote – Ohio; Columbus area preferred Duration... ...Perform clinical reviews of medical necessity appeals involving denied authorizations...Remote jobMedicalTemporary workWork at officeMonday to FridayShift work
- ...readmissions, while managing the denial process. This role addresses the MDH waitlist by identifying patients who no longer meet medical necessity criteria. Reviews are independent of treatment teams with objective feedback to hospitals. The position is hybrid with...Medical
- Blue Cross Blue Shield of Arizona needs a clinical expert for managing member and provider appeals. This remote position requires strong accuracy, knowledge of compliance timelines, and a focus on customer service. Applicants should possess a healthcare-related degree...Remote job
$28.94 - $51.83 per hour
...Clinical Appeals RN Optum is a global organization that delivers care, aided by technology... ...program specific regulations, medical necessity guidelines, standards of care and best... ...Management experience Appeals Experience Medicare/Medicaid experience preferred...Remote jobMedicalHourly payMinimum wageFull timeTemporary workWork experience placementWork at officeLocal area- ...resolving and responding to requests for member and provider appeals, grievances, reconsiderations and corrected claims for... ...related correspondence on a daily basis. Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine...Remote jobMedicalFull timeContract workWork at officeLocal area
$81.1k - $116.48k
Appeals and Grievances Clinical Specialist - RN, LPN or Dental Hygienist - 100% Remote Join to apply for the Appeals and Grievances Clinical... ..., prior approval, medical necessity, pre-certification, continued... ..., InterQual, Milliman, or Medicare guidelines. Proficiency with...Remote jobMedicalFull timeMonday to FridayShift work$52 per hour
...Hiring for RN - Appeals (Remote Role) in Somerville, MA Shift: Days 5x8 (08:00 - 17:00) Duration: 13 Weeks (Temp to Perm) Pay Rate: $5... ...least 2 years of Health Plan appeals experience ~ Works closely with our medical directors on case reviews and decisions...Remote workMedicalPermanent employmentTemporary workShift work$81.1k - $116.48k
Position Summary: The Appeals & Grievances (A&G)... ...subject matter expert responsible for... ...position is 100% Remote. We are hiring for... ..., prior approval, medical necessity, pre-certification... ...Qualifications: RN, LPN OR Dental Hygienist... ..., Milliman or Medicare local coverage guidelines...Remote jobMedicalContract workTemporary workWork experience placementLocal areaMonday to FridayShift work$70k - $80k
...Piper Companies is seeking a Remote Clinical Appeals Analyst to provide clinical expertise in reviewing... ...active North Carolina licensure as an RN, LPN, PT, or OT and have significant clinical... ...$80,000, along with company-subsidized medical, dental, and vision benefits. Key...Remote workMedicalFull timeContract workMonday to Friday- Optum is seeking a Utilization Management & Clinical Validation RN to review medical records, extract pertinent details, and craft defensible appeal letters. The role involves coding knowledge, literature references, and HIPAA compliance, with a telecommute option from...Remote jobMedical
$47 per hour
...RN – ICU PRN Subject Matter Expert (SME) Ready to share your expertise and make an impact—without leaving... ...setting to participate in a PRN remote Subject Matter Expert (SME) opportunity... ...300+ offices, our commitment to medical professionals is expressed through our...Remote workMedicalTemporary workFor contractorsInterim roleReliefLocal areaFlexible hours- ...care UM to perform pre-service and post-service utilization reviews and appeals for DMEPOS, working with our Medical Director in a NCQA-compliant UM program. You will review benefit and medical necessity criteria, coordinate with clinical and non-clinical staff, and...Remote jobMedical
- UnitedHealth Group is seeking an Utilization Management & Clinical Validation RN to accurately review medical records and extract case details, crafting defensible appeal letters using evidence-based literature and coding knowledge. You will work from anywhere in the U...Remote jobMedicalFlexible hours
$93 per hour
...Position: Denials Management & Appeals Manager Type: Contract... ...$93/hour Location: Remote Role Responsibilities... ...strategies across commercial, Medicare , and Medicaid payers.... ...clinical appeals including medical necessity, experimental/investigational...Remote workMedicalContract workSummer work$45 per hour
SPECTRAFORCE is seeking a Clinical Appeals Specialist to handle member-generated appeal processes remotely from California. The role involves reviewing medical records and ensuring compliance with... ...communication skills. A California RN license and ADN are required. The...Remote jobMedicalHourly pay- ...compliance with billing guidelines. Candidates should have an Associate's degree, an active RN or LPN license, and at least 2 years of clinical experience. Benefits include paid time off, medical plans, and a comprehensive benefits package. Enjoy flexibility to telecommute from...Remote jobMedical
- Medica, a nonprofit health plan, is seeking a remote Appeals & Grievances Clinical Specialist III to... ...STARs measures in focus, collaborating with medical directors and clinical staff. This position requires an active RN license and 5+ years of clinical experience,...Remote jobMedical
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