Nurse Appeals

Medical Appeals RN

Duration: 11/02/2026 - 08/31/2027

Location:

Columbus, OH 43085 (Virtual/Remote)

Schedule:

Ideal schedule is Tuesday-Saturday, 8:00 AM - 5:00 PM (40 hours/week)
Type:
Full-Time Contract
Business Unit: G1000

Responsible for investigating and processing medical necessity appeals submitted by members and providers. Reviews denied services, evaluates medical records, summarizes clinical findings, and provides recommendations to the Medical Director regarding appeal determinations. Ensures appeals and grievances are processed within regulatory time frames and generates written correspondence to providers, members, and regulatory entities.

• Investigate and review member and provider medical necessity appeals
• Review prospective, inpatient, and retrospective medical records for denied services
• Analyze and summarize clinical information for Medical Directors and external reviewers
• Prepare recommendations to uphold or overturn appeal determinations
• Ensure appeals and grievances are resolved within regulatory requirements
• Document and track appeal activity within designated systems
• Generate appeal-related correspondence
• Serve as a subject matter expert for appeals, grievances, and quality-of-care issues
• Support clinical and non-clinical staff in resolving escalated cases

• Active, unrestricted RN license in the United States
• Minimum 2 years of experience in a managed care healthcare setting
• High School Diploma or equivalent
• Strong written, verbal, analytical, and problem-solving skills
• Experience reviewing medical records and determining medical necessity

• Associate's or Bachelor's Degree in Nursing
• 4+ years of Care Management experience
• Medicare Appeals experience (strong preference)
• General business skills

Medical, dental, and vision insurance are available to qualified candidates who meet eligibility requirements.