Remote Appeals Registered Nurse – California

Job Title: Appeals Registered Nurse

Location: Remote – California

Work Arrangement: Remote

Employment Type: Contract-to-Hire

Duration: 6+ Months

Domain: Managed Care / Utilization Management / Appeals & Grievances

Pay Rate: $45.00 – $55.00/hr. on W2

Schedule: Monday – Friday | 9:00 AM – 5:00 PM

Deadline: 7/15/2026

Skills Required

Primary (Must-Have):

• Active California Registered Nurse (RN) License
• Minimum 2 years of Managed Care experience
• Minimum 2 years of Acute Care or Sub-Acute Nursing experience
• Experience with Medical Necessity Review and Utilization Management
• Experience reviewing Commercial and Medicare benefits
• Prior Authorization experience
• Pre-service and Post-service review experience
• Knowledge of MCG (Milliman Care Guidelines)
• Knowledge of National Coverage Determinations (NCD) and Local Coverage Determinations (LCD)
• Experience conducting medical record reviews and medical necessity determinations
• Strong analytical and clinical assessment skills
• Excellent written and verbal communication skills
• Proficiency with Microsoft Office Suite, Excel, Adobe PDF, Teams, SharePoint, and shared drives
• Ability to work independently and collaboratively within a team environment

Secondary (Good to Have):

• Appeals and Grievance Nursing experience
• Clinical Denials Management experience
• Utilization Review Nursing experience
• Knowledge of NCQA, CMS, DMHC, and DHCS regulations
• Experience working in fast-paced managed care environments
• Bachelor’s Degree in Nursing (BSN)

Position Overview

The Appeals Registered Nurse is responsible for reviewing and processing member-generated appeals, grievances, and clinical determinations for Commercial and Medicare members. This role involves extensive medical record review, application of medical necessity criteria, and collaboration with Medical Directors and cross-functional teams to ensure accurate and timely determinations while maintaining regulatory compliance.

Roles & Responsibilities

• Review and process first-level clinical appeals and grievances for Commercial and Medicare members
• Conduct comprehensive medical record reviews and evaluate supporting clinical documentation
• Analyze pre-service and post-service appeals involving medical necessity, benefit determinations, coding accuracy, and medical policy compliance
• Prepare accurate and well-supported clinical determination documentation
• Apply MCG, NCD, LCD, NCCN, ACOG, and other nationally recognized clinical guidelines
• Evaluate services for medical necessity and coverage eligibility
• Identify discrepancies and inaccuracies in medical records and clinical documentation
• Ensure compliance with company policies, accreditation requirements, and regulatory standards
• Collaborate with Medical Directors on complex appeal cases
• Partner with Utilization Management, Pharmacy, Claims, Customer Service, Quality, and Care Management teams
• Communicate appeal outcomes and required follow-up actions
• Participate in clinical discussions to ensure consistency in decision-making
• Maintain compliance with NCQA, CMS, DMHC, DHCS, and organizational requirements
• Meet regulatory turnaround times and service level expectations
• Support quality improvement initiatives related to appeals and utilization management processes
• Maintain accurate documentation and case records
• Perform additional duties as assigned

Minimum Qualifications

• Associate Degree in Nursing (ADN) required
• Active California Registered Nurse (RN) License required
• Minimum 2 years of Managed Care experience
• Minimum 2 years of Acute Care or Sub-Acute Clinical Nursing experience
• Experience with Medical Necessity Review and Utilization Management
• Experience reviewing Commercial and Medicare benefits
• Prior Authorization experience
• Experience with pre-service and post-service reviews
• Strong analytical, documentation, and communication skills

Preferred Qualifications

• Bachelor of Science in Nursing (BSN)
• Appeals & Grievance Nursing experience
• Clinical Denials Management experience
• Utilization Review Nursing experience
• Knowledge of NCQA, CMS, DMHC, and DHCS regulations
• Experience working in managed care environments
• Strong clinical assessment and decision-making skills

Work Environment

• Fully remote position within California
• Fast-paced managed care environment
• Extensive medical record review and documentation responsibilities
• Frequent collaboration with Medical Directors and cross-functional teams
• Independent work with strong emphasis on quality, compliance, and regulatory timelines

Benefits

Medical | Dental | Vision | 401(k) | Paid Sick Leave

EEOC Compliance

We are an equal opportunity employer, and all qualified applicants will receive consideration for employment.

Disclaimer

AI Usage Policy: Pacer Group uses AI to assist in screening applications. Final hiring decisions are made by human recruiters based on qualifications and experience.