Registered Nurse (Claims & Appeals Review)

Overview Job Title: Registered Nurse – Claims & Appeals Review Location: Remote (Anywhere in Florida) Duration: 06 Months/Can be Extended Working hours: Day Shift Job Type: Subcon Pay Rate: Negotiable Position Description The Quality Analyst is responsible for ensuring the accuracy, compliance, and timeliness of appeal reviews through both manual and automated reporting mechanisms. This role supports continuous improvement in clinical operations by identifying quality gaps, performing root cause analysis, and recommending corrective actions. Key Responsibilities Review appeal cases and supporting documentation to ensure completeness and compliance with InterQual and contractual guidelines. Conduct manual audits and reporting to assess quality of appeal decisions and documentation. Analyze operational data and performance metrics to identify trends, errors, and improvement opportunities. Collaborate with clinicians and MD reviewers to validate decisions and escalate complex cases. Maintain dashboards and SLA tracking for appeals turnaround time, audit coverage, and accuracy. Support calibration sessions and feedback loops with transaction monitors and team leads. Document findings and prepare reports for internal and client-facing reviews. Ensure compliance with NCQA, CMS, and state regulations. Qualifications Education/Experience Bachelor’s degree in healthcare, life sciences, or related field preferred 2+ years of experience in appeals, grievance, or quality assurance in a healthcare setting Experience with audit tools, EMR systems, and reporting platforms Licensure/Certification Valid RN, LPN, or LVN license in applicable state (Florida) Skills Strong analytical, leadership and documentation skills Proficiency in Excel and data visualization tools Familiarity with InterQual criteria and CMS guidelines Ability to work independently and manage multiple priorities Additional Details Seniority level: Mid-Senior level Employment type: Contract Job function: Health Care Provider Industries: Hospitals and Health Care and Public Health #J-18808-Ljbffr Compunnel Inc.