Medicare Appeals Nurse (LPN)

Job Description

Job Description

Job Title: Medicare Appeals Nurse (LPN)

Location: Fully Remote, Arizona residents highly preferred

Pay: $30.00-$34.00/hour, based on experience and qualifications

Schedule: Monday-Friday, 8:00 AM-5:00 PM CST, with required weekend rotation

Position Type: W2 Temp-to-hire, initial 6-month assignment with potential for extension or conversion to full-time based on business needs. Benefits are available to full-time employees after 90 days of employment.

Job Overview

We are seeking an experienced Medicare Appeals Nurse (LPN) to join a remote clinical review team responsible for evaluating pre-service authorization denials and retrospective claim denials for Medicare members and providers nationwide. This role focuses on determining medical necessity by reviewing clinical documentation, applying established Medicare guidelines, and supporting appropriate access to medically necessary healthcare services.

The Medicare Appeals Nurse will review medical records, evaluate authorization requests and denied claims, update authorization information, and collaborate closely with physician reviewers to support final medical necessity determinations. Cases are assigned through a round-robin process, and clinicians work closely with supervisors, senior clinicians, and coordination teams to ensure timely case completion. The team collaborates regularly through Microsoft Teams for case discussions, guidance, and ongoing support.

This position supports multiple Medicare markets across the country and plays an important role in ensuring consistent, evidence-based clinical review while helping improve member outcomes and provider experience.

Key Responsibilities

• Perform clinical reviews for Medicare pre-service authorization denials and retrospective claim denials.
• Review medical records and clinical documentation to determine medical necessity.
• Apply Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and InterQual or Milliman criteria during clinical reviews.
• Review, update, and maintain authorization information within multiple clinical review platforms.
• Collaborate with physician reviewers to support final medical necessity determinations.
• Work closely with supervisors, senior clinicians, and care coordination teams throughout the appeals review process.
• Maintain accurate documentation while meeting productivity and quality expectations.
• Participate in the required weekend rotation schedule.

Required Qualifications

• Active Licensed Practical Nurse (LPN) license.
• Previous experience performing Utilization Management or Appeals clinical reviews.
• Medicare Appeals experience.
• Working knowledge of Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD).
• Experience using InterQual or Milliman clinical review software.
• Experience performing retrospective claims clinical reviews.

Preferred Qualifications (Not Required)

• Associate Degree in Nursing, Bachelor's Degree in Nursing, or higher.
• Experience reviewing cases across multiple utilization management platforms.

Performance Expectations

• Meet daily productivity expectations based on assigned review platform:
• Prime: 7 cases per day.
• iCP: 9 cases per day.
• CenPas: 20 cases per day.
• Maintain a minimum quality score of 95% across all completed clinical reviews.

Why Apply

• Fully remote opportunity.
• Competitive hourly pay based on experience and qualifications.
• Join an established Medicare Appeals team supporting members across multiple markets nationwide.
• Collaborative virtual team environment with ongoing support from experienced clinical leadership.
• Opportunity for contract extension or conversion to a full-time position based on business needs.