Clinical Appeals RN
Job Title: RN Appeals Reviewer
Pay Rate: $40/hr (Paid Weekly)
Address: Remote
Allmed Benefits: Vision Insurance, Health Insurance, Dental Insurance, and 401(k)
Contract: 01/19/2026 to 04/17/2026
Position Overview
We are seeking a dedicated and experienced RN Appeals Reviewer to join our team. The ideal candidate will be responsible for conducting comprehensive reviews of member and provider appeals, ensuring all decisions align with organizational policies, benefit plans, regulatory requirements, and clinical criteria. This role requires strong clinical judgment, analytical skills, and the ability to balance accuracy with productivity expectations.
Key Responsibilities
Conduct detailed reviews of member and provider appeals, including clinical documentation and supporting materials.
Analyze claim adjustments, claim histories, and previous determinations to ensure consistency and accuracy.
Evaluate denied services in accordance with policies, benefit plans, state and federal regulations, and evidence-based clinical guidelines.
Render approvals when criteria are met and ensure all determinations are thoroughly documented.
Summarize complex medical information for escalation and review by the Medical Director, as needed.
Maintain a high standard of quality while meeting established production and timeliness goals.
Ensure all work adheres to compliance standards, confidentiality requirements, and organizational procedures.
Qualifications
Active and unrestricted Registered Nurse (RN) license.
Demonstrated experience in appeals review, reconsideration review, or similar clinical review functions.
Strong knowledge of medical terminology, clinical review processes, and health plan operations.
Experience with utilization review or clinical claims review is preferred.
Excellent analytical, critical thinking, and written communication skills.
Ability to work independently while maintaining accuracy and efficiency.
Recommended Jobs
Maintenance Tech. (Commercial/Industrial)
**Job Description** _Maintenance Technician - Needs to be open all Shifts | Pay: $28.79/hour_ **Position Overview** Amazon Air is seeking a skilled and reliable Maintenance Technician to support opera…
Experience the Heart of Ohio: Travel Nursing Awaits!
Registered Nurse - Progressive Care - Travel - (PCU RN) Embark on an exhilarating travel nursing adventure in Columbus, Ohio! Join the prestigious Arthur G. James Cancer Hospital as a PCU RN and imme…
Business Process Engineer
**Company :** Highmark Inc. **Job Description :** **JOB SUMMARY** This job leads, supports and facilitates process improvement initiatives across multiple functional units for both strategic and conti…
Inpatient Medical Coder III Hybrid
Job Details Experienced Naval Medical Center Portsmouth VA - Portsmouth VA Full Time 2 Year Degree $32.00 - $32.46 Hourly Health Care/Medical Inpatient Medical Coder III …
Explore Chardon's Heart: Travel Nursing Adventure Awaits!
Registered Nurse - Cardiac Catheterization Lab - Travel - (Cath Lab RN) Join us in Chardon, where the heartbeats flow, As a Cath Lab RN, let your skills really glow. With a team that's driven, and …
Chiropractor Middleburg Heights, Ohio
Chiropractor Full Time/Part Time Location: Middleburg Heights Ohio A better way to deliver care starts here! The Joint Chiropractic is revolutionizing access to care by delivering high-quali…
RN ED Full Time MIDSNO WEEKENDS!
Why ThedaCare Living A Life Inspired! Our new vision at ThedaCare is bold ambitious and ignited by a shared passion to provide outstanding care. We are inspired to reinvent health care by be…
APQP Program Leader-2
Job Description Summary The APQP Project Leader will drive deployment of Advanced Product Quality Planning within GE Aerospace's internal organization and supply base to ensure engine products tha…
RN Homecare - Full Time Days / Nights
Job Description Salary: $32-$35 / per hour * 1 on 1 Private Duty Nursing in a Home Setting. * Flexible Schedules (Create your Own). * Full Shifts (8,10,12 Hours) * Pediatric, trach and vent training…
Anesthesiologist in Cincinnati, Ohio
Join an award-winning team of dedicated clinicians who are committed to providing world-class patient care! TeamHealth is seeking a full-time anesthesiologist for expanding services. You will join our…