Appeals Processor III - RN

Appeals Processor III - RN

• salary

• Unavailable

• Hours per week

• 40

• Shifts

• 5/8's

• Start Date

• Unavailable

• Duration

• 52 Weeks

• Job Number

• 1094

We are seeking a highly skilled Appeals Processor III (APP III) to join our dedicated team in a remote capacity. The Appeals Processor III (APP III) is responsible for reviewing, analyzing, and processing healthcare appeals related to Medicaid or Medicare coverage decisions. This role ensures all cases are handled in compliance with federal/state regulations, CMS guidelines, and contract requirements.

Qualification and Requirements

Requirements

• Associate's Degree (Bachelor's preferred)

• 2+ years in:

• Healthcare appeals

• Medical claims / utilization review

• Insurance or Medicaid/Medicare processing

• Strong knowledge of:

• CMS guidelines

• Medicaid/Medicare (especially Part C)

• Experience reviewing medical documentation (clinical roles may require RN)

Responsibilities

Duties

• Review incoming appeals, medical records, and supporting documentation

• Analyze cases using state/federal regulations and CMS guidelines

• Determine if additional documentation is required and request it when needed

• Process appeals from start to finish, including final determinations

Decision Support & Documentation

• Prepare case summaries and ensure files are complete for review

• Draft or support writing determination/decision letters

• Ensure all documentation meets quality and compliance standards

GhostRX, Inc. is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, sexual orientation, and gender identity), national origin, age, disability, genetic information, protected veteran status, or any other characteristic protected by applicable law.

If you are unable to apply due to a disability, you may request a reasonable accommodation by contacting View email address on click.appcast.io or dialing 711 (TTY).

This contractor and subcontractor abides by the requirements of 41 CFR 60-1.4(a), 41 CFR 60-300.5(a), and 41 CFR 60-741.5(a). These regulations prohibit discrimination against qualified individuals on the basis of protected veteran status or disability and require affirmative action by covered prime contractors and subcontractors to employ and advance in employment qualified protected veterans and individuals with disabilities.

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EOE: race/color/religion/sex/sexual orientation/gender identity/national origin/age/genetic information/pregnancy/disability/protected veterans