Appeals Registered Nurse

About the role

The Appeals Registered Nurse reviews medical records and claim information for first‑level appeal cases to determine medical necessity and Medicare coverage compliance. This role works remotely with a team of Appeals Examiners and Redetermination Representatives to ensure timely, accurate redeterminations.

Key responsibilities

• Review and assess first‑level appeal cases for denied services, ensuring all required documentation and coding are present.
• Conduct comprehensive medical record reviews to evaluate clinical necessity and recommend resolutions based on guidelines and policies.
• Prepare and submit detailed appeal letters with rationales and supporting clinical evidence.
• Follow up on appeals to achieve proper resolution within company policies and regulatory timelines.
• Maintain awareness of healthcare laws, regulations, and Medicare policies relevant to the appeals process.
• Guide Redetermination Representatives to ensure clinical decisions meet CMS quality and timeline standards.

Required profile

• Associate’s or Bachelor’s degree in Nursing (BSN) and an active RN license in good standing.
• At least one year of clinical experience in a healthcare setting (hospital, case management, skilled nursing, etc.).
• Excellent written and verbal communication skills with strong attention to detail.
• Basic knowledge of medical/clinical review processes such as appeals and utilization review.
• Proficiency with multiple online systems and Microsoft Office applications.

Required skills

• Microsoft Outlook
• Microsoft Teams
• OneNote
• Word
• Excel

What we offer

• Salary range $66,000 – $68,000 per year (base pay varies with experience and skills).
• Remote work opportunity in approved U.S. states.
• Collaborative environment with clear career development pathways.