Clinical Appeals Reviewer – Remote (Licensed Healthcare Professional)

About the role

This fully remote position involves independent, evidence‑based reviews of medical appeals for federal healthcare programs. As a Clinical Appeals Reviewer you will apply your clinical expertise to assess medical necessity, ensure compliance with regulations, and produce clear, defensible decisions that impact beneficiaries and providers.

Key responsibilities

• Review medical records and case files to determine medical necessity and appeal outcomes.
• Prepare concise, well‑reasoned reconsideration decision letters supported by clinical evidence.
• Conduct independent clinical reviews aligned with federal laws, Medicare regulations, and policy guidelines.
• Address all appeal issues raised by patients, providers, or representatives.
• Research medical literature, coverage policies, and regulatory guidance to support determinations.
• Participate in case discussions, quality reviews, and cross‑functional meetings.
• Serve as a subject‑matter resource and mentor other staff when required.

Required profile

• Active license as an RN, PT, OT, RT, or other qualified healthcare professional.
• Minimum 3 years of experience in medical review, Medicare appeals, utilization review, or related clinical decision‑making roles.
• Strong knowledge of Medicare regulations, coverage rules, and healthcare compliance frameworks.
• Ability to make independent, evidence‑based determinations and document complex clinical reasoning with precision.

Required skills

• Interpretation of clinical data, policies, and regulatory documentation.
• Research of medical literature, coverage policies, and regulatory guidance.
• Clear, concise written communication for decision letters.