Appeals Nurse Reviewer: Medical Necessity & Compliance
Arkansas Blue Cross
Arkansas Blue Cross and Blue Shield is seeking an experienced RN to review appeals of adverse benefit determinations. You will research medical necessity and coverage policy, and exercise independent judgment to ensure fair, compliant decisions. The role requires an active RN license with 5 years of clinical nursing and at least 2 years in utilization review. You will collaborate with medical divisions and respond to state insurance department complaints. #J-18808-Ljbffr
Vacancy posted 11 hours ago
Similar jobs that could be interesting for youBased on the Appeals Nurse Reviewer: Medical Necessity & Compliance in New York, NY vacancy
$65k - $75k
...Description Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with... ...Directors, as necessary, to ensure compliance with review timeframes.... ...requirements in collaboration with Nursing Management. Keeps current with...MedicalFull timeWork at officeLocal areaRemote workMonday to Friday- ...Elevance Health is seeking a Nurse Appeals professional to investigate and process medical necessity appeals for members and providers. The role supports remote work... ...and adherence to commuting guidelines. You will review records, summarize findings, and determine payment...MedicalRemote work
Elevance Health
New York, NY4 days ago - Clinical Appeals Nurse (RN) Status: Exempt Location: Remote Department:... ...revenue cycle operations by reviewing denied claims for clinical accuracy and medical necessity, developing evidence-based appeal... ...outcomes, and ensuring compliance with payer policies and clinical...MedicalRemote work
$66k - $106k
...performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and... ...in the medical field as a Registered Nurse or other clinician, and/or experience... ...medical claims for coverage and medical necessity. Current/Active Nursing or Physical Therapy...MedicalContract workTemporary workRemote workShift workNight shiftPeraton
New York, NY8 hours ago- ...a Physician to provide utilization review services. The successful candidate will... ...clinical expertise to review medical records and ensure compliance with guidelines. This role includes reviewing prior authorizations and appeals, maintaining proper licensure, and tackling...Medical
Dane Street
New York, NY4 days ago - ...Health Business Solutions LLC is seeking a Clinical Appeals Nurse (RN) for a remote role. The position focuses on reviewing denied claims for clinical accuracy and medical necessity, developing appeal strategies, and drafting payer-ready documentation to overturn denials...MedicalRemote work
Health Business Solutions
New York, NY2 days ago - ...and post-service utilization reviews and appeals within a NCQA-compliant UM program... ...You will collaborate with our Medical Director to assess benefit and medical necessity criteria and handle related... ...as LPN/LVN, at least 3 years nursing experience, and 2+ years UM experience...MedicalRemote work
Integra Partners
New York, NY4 days ago - ...-service and post-service utilization reviews and appeals. You will collaborate with our Medical Director to review benefit and medical necessity and support NCQA-compliant UM processes... ...our program. The role requires active nursing licensure, 3+ years of nursing, and 2+...MedicalRemote work
Integra Partners
New York, NY9 hours ago - ...Dane Street, LLC is seeking an experienced Registered Nurse to perform reviews and clinical summaries for disability claims. Reports must generally... ...reporting. The role emphasizes professional, concise medical writing, clear layman explanations, and adherence to #J-188...Medical
Dane Street
New York, NY4 days ago - ...LVN with UM experience to perform pre-service and post-service utilization reviews and appeals for DMEPOS. You will collaborate with the Medical Director to ensure benefit and medical necessity reviews align with NCQA standards within a UM program. Responsibilities...MedicalRemote work
Integra Partners
New York, NY2 days ago - ...Partners is seeking a Licensed Practical Nurse (LPN/LVN) with experience in managed... ...service and post-service utilization reviews and appeals for DMEPOS. The role collaborates with our Medical Director on benefit and medical necessity reviews within an NCQA-compliant UM...MedicalRemote work
Integra Partners
New York, NY6 hours ago - ...Job Title: Clinical Reviewer – Nurse (RN) Maternal Health Position Type: Full-Time, 1-Year Contract (40 Hours/Week)... ...record reviews for high-impact healthcare quality and compliance initiatives. You will synthesize medical records, interview transcripts, and clinical data...MedicalFull timeContract workWork at officeMonday to FridayFlexible hours
Medix
New York, NY2 days ago - ...managed care experience to perform pre-service and post-service utilization reviews and appeals for DMEPOS. You will collaborate with our Medical Director to ensure benefit and medical necessity reviews meet NCQA UM standards, using InterQual and CMS guidelines. The...MedicalRemote work
Integra Partners
New York, NY2 days ago $78k - $99.2k
...It takes great medical minds to create powerful solutions that solve some of healthcare... ...a talented individual for a Senior Nurse Reviewer to perform reviews of medical records,... ...bill, and UB-04 forms to ensure accuracy, compliance, and proper billing practices. This position...MedicalFull timeRemote workWork from homeFlexible hoursGainwell Technologies LLC
New York, NY2 days ago$52 - $56 per hour
...RN Grievance & Appeals Specialist | Remote | ContractRNs with direct, payer-side Grievance & Appeals experience —... ...through the final determination letter. This is a clinical review role requiring strong medical necessity knowledge, regulatory awareness, and the ability to...MedicalRemote workAfternoon shiftPhaxis
New York, NY9 hours ago- ...remote LPN Utilization Management Nurse to perform pre-service and post-service utilization reviews for DMEPOS, ensuring NCQA standards and medical necessity criteria. The role collaborates with... ...communicate outcomes, and support appeals. It requires strong UM experience...MedicalFull timeRemote work
Integra Partners Holdings, Inc.
New York, NY10 hours ago - HealthEdge is seeking a remote (US) Appeals & Grievances Specialist to independently process complex grievances and conduct medical necessity reviews across inpatient, outpatient, and ancillary services. You will prepare documentation for regulatory standards and coordinate...MedicalRemote job
$52 - $56 per hour
...Health PlanYou've done UM. You've worked appeals. Now find a role that uses both. We're... ...letter, and you'll apply the same medical necessity judgment you built in utilization management... ...end: intake, investigation, clinical review, decision and notificationApply medical...MedicalContract workRemote workAfternoon shiftPhaxis
New York, NY9 hours ago- Americare in Brooklyn, NY seeks a dedicated RN Quality Reviewer to ensure documentation accuracy and CMS-compliant OASIS assessments. This full-time on-site role supports COC teams in a dynamic home health setting. Ideal candidates will have NYS RN licensure, strong documentation...Full time
- BlueCross BlueShield of South Carolina is seeking a nurse to research the substance of complex appeal requests, perform clinical review to determine medical necessity, and document decisions within required timeframes. This full-time remote role (40 hours/week, 8 a.m.-...MedicalRemote jobFull timeLocal area
- ...Description Job Description LTSS Appeals Nurse (Remote) We are seeking a... ...perform high-volume clinical reviews within the appeals process, evaluating complex medical records and Long-Term Services... ...regulatory and medical necessity criteria. Job Responsibilities...MedicalLocal areaRemote workMonday to FridayFlexible hoursShift work
Medix
New York, NYa month ago - Anticipated End Date 2026-11-16 Position Title Nurse Appeals Job Description Nurse Appeals... ...for investigating and processing and medical necessity appeals requests from members and... ...an impact Conduct investigations and reviews of members and provider medical necessity...MedicalFull timeTemporary workLocal area1 day per week
$53.46k
...the substance of complex appeal or retrospective review requests including pre-pay... ...requested services meet medical necessity guidelines. Documents decisions... ...timeframes and in compliance with applicable regulations... ...: Associate Degree - Nursing or Graduate of Accredited...MedicalFull timeFor contractorsWork experience placementLocal areaRemote workMonday to FridayShift work- SetPoint Medical’s Market Access Specialist will facilitate patient... ..., and internal teams. Review and log incoming medical record... ...Coordinate the pre-service appeals process, including composition... ...standards. Experience with HIPAA compliance standards for covered...MedicalRemote work
- ...remote position overseeing utilization management and complex appeals processes for US members and providers. The role requires... ..., with strong analytical and communication skills to handle medical necessity reviews and written correspondence efficiently. #J-18808-Ljbffr...MedicalRemote work
Bundesverband der Personalmanager e.V.
New York, NY9 hours ago - ...an experienced RN to lead utilization review activities at our Hamilton, NY facility... ...and pre-admission reviews to determine medical necessity and level of care. Work with physicians... ...support cost containment while ensuring CMS and Joint Commission compliance. #J-18808-Ljbffr...Medical
Community Memorial Health System
New York, NY4 days ago $81.1k - $116.48k
Appeals and Grievances Clinical Specialist - RN, LPN or Dental Hygienist... ...and resolution, ensuring compliance with regulations. The role... ...conditions, prior approval, medical necessity, pre-certification,... ...colleagues and prepare cases for review and appeals. Minimum Qualifications...MedicalRemote jobFull timeMonday to FridayShift work- ...providing guidance on medical necessity, utilization management... ...teams to ensure compliance with regulatory standards... ...Functional Duties: Utilization Review: Review medical... ...Management: Lead the denial appeal process to optimize... ...with physicians, nurses, administrators, and other...MedicalFull timePart time
- ...Ladders seeks a Remote Medical Director - Appeals to lead medical oversight of utilization... ...processes. The role involves reviewing complex cases, guiding medical necessity decisions, and partnering with... ...emphasizes regulatory compliance, performance improvement, and...MedicalRemote work
Ladders
New York, NY3 days ago $275k - $315k
...Title: Medical Director of Utilization Management Summary:... ...for UM services, complex case reviews, appeals, and peer-to-peer discussions... .... Ensure regulatory compliance and lead departmental preparation... .../outpatient UM, medical necessity, pharmacy, and appeals. Certifications...MedicalFull timeWork at officeRemote workMonday to FridayShift work2 days per weekMedix™
New York, NY2 days ago
Do you want to receive more vacancies?
Subscribe and receive similar vacancies to Appeals Nurse Reviewer: Medical Necessity & Compliance. Be the first to apply!
Related searches
- medical customer service representative New York, NY
- medical and health service manager New York, NY
- medical driver New York, NY
- non emergency medical transportation New York, NY
- medical director global medical affairs New York, NY
- medical surgical nurse New York, NY
- medical delivery driver New York, NY
- medical solutions New York, NY
- product specialist medical New York, NY
- medical payment poster New York, NY