Remote Clinical Appeals RN – Compact License

Position: Clinical Appeals Nurse (Medicare)

Client: Health Insurance Client

Location: 100% Remote (EST Hours)

Start Date: ASAP

Key Responsibilities

• Review and evaluate Medicare appeals cases (pre-service and post-service)
• Conduct clinical documentation review and apply medical necessity criteria
• Draft appeal determinations using standardized templates
• Ensure complete and accurate documentation, including attachments
• Manage case workload aligned to productivity expectations (~5/day)
• Collaborate with internal teams and perform required outreach as needed
• Utilize AI-assisted tools while maintaining clinical judgment

Top Denial Types / Case Mix

• Pre-service / expedited appeals (high priority)
• Radiology denials
• Durable Medical Equipment (DME)
• Dual-eligible / waiver services (e.g., PCS)

Required Qualifications

• Active Registered Nurse (RN) license (compact preferred)
• Strong experience in clinical appeals, preferably Medicare
• Background in payer-side utilization management or appeals
• Experience with:
• GuidingCare (preferred)
• Facets (preferred)
• Strong clinical documentation and writing skills
• High attention to detail (audit-sensitive environment)