Appeals Clinical Reviewer

Job Title:

Appeals Clinical Reviewer

Job Description

The Appeals Clinical Reviewer serves as an Appeals Utilization Review Nurse responsible for reviewing and evaluating member and provider appeals related to medical necessity determinations, authorization decisions, and claims outcomes. This role applies clinical expertise, evidence-based guidelines, regulatory requirements, and internal policies to ensure appeal determinations are fair, timely, and compliant. The nurse collaborates closely with Medical Directors, providers, claims teams, and utilization management staff to support high-quality patient care while promoting appropriate utilization of healthcare services.

This is a remote opportunity with potential for permanent placement.

Responsibilities

+ Review and evaluate member and provider appeals related to medical necessity determinations, authorization decisions, and claims outcomes.

+ Apply clinical expertise and evidence-based guidelines to assess the appropriateness of healthcare services under appeal.

+ Ensure appeal determinations comply with regulatory requirements, Medicaid program rules, and internal company policies.

+ Document clinical reviews and appeal decisions clearly, accurately, and in a timely manner.

+ Collaborate with Medical Directors to discuss complex cases and support consistent, high-quality clinical decision-making.

+ Work closely with providers to clarify clinical information and ensure accurate interpretation of medical records and treatment plans.

+ Partner with claims teams to align appeal outcomes with claims processing and benefit coverage rules.

+ Coordinate with utilization management staff to support appropriate utilization of healthcare services and adherence to utilization review processes.

+ Support quality patient care by balancing member needs with responsible resource utilization.

+ Maintain up-to-date knowledge of utilization management practices, Medicaid requirements, and relevant clinical guidelines.

+ Adhere to all timelines and procedural requirements for appeal review to ensure timely resolution of cases.

Essential Skills

+ Active Florida Registered Nurse (FL RN) license.

+ At least 2 years of utilization management (UM) or utilization review (UR) experience.

+ At least 2 years of Medicaid experience.

+ Demonstrated experience in clinical review within a managed care or similar environment.

+ Strong understanding of utilization management and utilization review principles.

+ Knowledge of Medicaid regulations, requirements, and benefit structures.

+ Ability to interpret and apply evidence-based clinical guidelines to appeal reviews.

+ Proficiency in documenting clinical decisions clearly and accurately.

+ Strong collaboration skills for working with Medical Directors, providers, claims teams, and utilization management staff.

+ Ability to manage time effectively and meet strict appeal turnaround requirements.

Additional

Skills & Qualifications

+ Experience in managed care environments and health plan operations.

+ Familiarity with utilization management systems and clinical documentation tools.

+ Strong analytical and critical thinking skills to evaluate complex clinical information.

+ Excellent written and verbal communication skills for interacting with internal teams and external providers.

+ Ability to work independently in a remote setting while maintaining productivity and quality standards.

Work Environment

This role operates in a 100% remote work environment, allowing the nurse to perform all responsibilities from a home-based or remote office setting. The standard schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m., providing consistent daytime hours. The position involves frequent collaboration with Medical Directors, providers, claims teams, and utilization management staff through virtual communication tools. The role offers the opportunity to transition to a permanent position, providing long-term career potential in a remote managed care and utilization review setting.

Job Type & Location

This is a Contract to Hire position based out of Sunrise, FL.

Pay and Benefits

The pay range for this position is $30.00 - $40.00/hr.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:  - Medical, dental & vision
- Critical Illness, Accident, and Hospital  - 401(k) Retirement Plan
- Pre-tax and Roth post-tax contributions available
- Life Insurance (Voluntary Life & AD&D for the employee and dependents)  - Short and long-term disability
- Health Spending Account (HSA)  - Transportation benefits
- Employee Assistance Program
- Time Off/Leave (PTO, Vacation or Sick Leave)

Workplace Type

This is a fully remote position.

Final date to receive applications

This position is anticipated to close on Jul 14, 2026.

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