Appeals Registered Nurse

Role Snapshot The Appeals Nurse examines medical records and claims information for first-level appeal cases to determine whether services provided were medically necessary and meet Medicare coverage guidelines in accordance with Medicare regulations and policies. The Appeals RN works in collaboration with the Appeals Examiners/Reps to ensure redeterminations are medically reviewed as needed and completed timely. Salary Range 66-68k. The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience. Work Location We are open to remote work in the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin. Responsibilities Review and assess first-level appeal cases for denied services, ensuring all relevant medical documentation, coding, and clinical information are provided to support the appeal. Conduct comprehensive medical record reviews to determine the clinical necessity of services and make recommendations for resolution based on clinical guidelines, policy, and the medical necessity of care. Prepare and submit written appeal letters, including comprehensive rationales and supporting clinical evidence. Ensure timely follow-up on all appeals and ensure proper resolution is reached in accordance with company policies and external regulations. Maintain awareness of healthcare laws, regulations, and policies relevant to the appeals process, ensuring all actions comply with regulatory and contractual requirements. Work with and provide directions to Redetermination Representatives to ensure all redeterminations, which require a clinical decision, are responded to within CMS quality and timelines standards. Minimum Qualifications Associate's (ASN) or Bachelor's Degree in Nursing (BSN). Active RN license, applicable to state of practice in good standing. One or more years of clinical experience in a healthcare setting (hospital/bedside, case management, MDS/Skilled Nursing, etc.). Excellent written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely. Strong attention to detail and organizational skills to manage multiple cases simultaneously. Basic knowledge and understanding of medical/clinical review processes (i.e., Appeals/Utilization Review). Solid computer skills with experience working in multiple online systems including MS Outlook, Teams, OneNote, Word, and Excel. Preferred Qualifications Experience working for a Medicare Administrative Contractor (MAC) preferred. One or more years of experience working in Medical Management (e.g., MDS role), Medical Review, Utilization Management/Review, or Appeals preferred. Basic Medicare knowledge and/or experience preferred. Remote Work Requirements Wired (ethernet cable) internet connection from your router to your computer. High speed cable or fiber. Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at Please review Remote Worker FAQs for additional information. Benefits Remote and hybrid work options available. Performance bonus and/or merit increase opportunities. 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately). Competitive paid time off. Health insurance, dental insurance, and telehealth services start DAY 1. Professional and Leadership Development Programs. Review additional benefits: ( ). Equal Opportunity Employer Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities. This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor. #J-18808-Ljbffr