Healthcare Nurse - Remote

Appeals Processor III - RN

• Shifts
• 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.

Associate's Degree (Bachelor's preferred)

• Healthcare appeals
• Medical claims / utilization review
• CMS guidelines
• Experience reviewing medical documentation (clinical roles may require RN)

Review incoming appeals, medical records, and supporting documentation

Analyze cases using state/federal regulations and CMS guidelines

Draft or support writing determination/decision letters

Ensure all documentation meets quality and compliance standards

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 [email protected] 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