Job Description & How to Apply Below
Overview
Job Title: Registered Nurse – Claims & Appeals Review
Location: Remote (Anywhere in Florida)
Duration: 06 Months/Can be Extended
Working hours: Day Shift
Job Type: Subcon
Pay Rate: Negotiable
Position DescriptionThe Quality Analyst is responsible for ensuring the accuracy, compliance, and timeliness of appeal reviews through both manual and automated reporting mechanisms. This role supports continuous improvement in clinical operations by identifying quality gaps, performing root cause analysis, and recommending corrective actions.
Key Responsibilities- Review appeal cases and supporting documentation to ensure completeness and compliance with Inter Qual and contractual guidelines.
- Conduct manual audits and reporting to assess quality of appeal decisions and documentation.
- Analyze operational data and performance metrics to identify trends, errors, and improvement opportunities.
- Collaborate with clinicians and MD reviewers to validate decisions and escalate complex cases.
- Maintain dashboards and SLA tracking for appeals turnaround time, audit coverage, and accuracy.
- Support calibration sessions and feedback loops with transaction monitors and team leads.
- Document findings and prepare reports for internal and client-facing reviews.
- Ensure compliance with NCQA, CMS, and state regulations.
- Bachelor’s degree in healthcare, life sciences, or related field preferred
- 2+ years of experience in appeals, grievance, or quality assurance in a healthcare setting
- Experience with audit tools, EMR systems, and reporting platforms
- Valid RN, LPN, or LVN license in applicable state (Florida)
- Strong analytical, leadership and documentation skills
- Proficiency in Excel and data visualization tools
- Familiarity with Inter Qual criteria and CMS guidelines
- Ability to work independently and manage multiple priorities
- Seniority level:
Mid-Senior level - Employment type:
Contract - Job function:
Health Care Provider - Industries:
Hospitals and Health Care and Public Health
To View & Apply for jobs on this site that accept applications from your location or country, tap the button below to make a Search.
(If this job is in fact in your jurisdiction, then you may be using a Proxy or VPN to access this site, and to progress further, you should change your connectivity to another mobile device or PC).
(If this job is in fact in your jurisdiction, then you may be using a Proxy or VPN to access this site, and to progress further, you should change your connectivity to another mobile device or PC).
Search for further Jobs Here:
×