Clinical Appeals Nurse - Medicare

Medasource; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

Medasource is seeking an experienced Clinical Appeals Registered Nurse (RN) to support the Medicare appeals team for a leading healthcare insurance client. This fully remote opportunity focuses on reviewing clinical appeals, evaluating medical necessity, and ensuring timely determinations per Medicare guidelines.

The ideal candidate has direct Medicare clinical appeals experience, strong utilization review knowledge, and can work independently in a fast-paced environment.

Qualifications

• Active RN license required.
• Direct Medicare clinical appeals experience required.
• Associate degree in Nursing or equivalent.
• Experience with medical necessity reviews and appeal determinations.
• Inpatient/outpatient appeals experience preferred.
• Payer-side Medicare/Medicaid/commercial experience preferred.

Responsibilities

• Review Medicare clinical appeals submitted by members and providers within required timeframes.
• Evaluate denied claims and medical necessity criteria to support accurate determinations.
• Handle inpatient and outpatient appeals, including expedited requests, radiology, and DME denials.
• Apply Medicare regulations, medical policies, and clinical review guidelines to ensure compliance.
• Prepare appeal determinations, notification letters, and supporting documentation.
• Collaborate with medical directors and internal teams to maintain accuracy and productivity.

Skills

Active RN license

Direct Medicare appeals experience

Independent work

Education

Associate degree in Nursing

Tools

MCG

InterQual

CMS guidelines

Facets

Job description

Job Title: Clinical Appeals Nurse - Medicare

Location: 100% Remote (United States)

Schedule: Monday–Friday | 8:00 AM–5:00 PM EST

Employment Type: Full-Time | W2 Contract

Contract Length: Initial 3 months with potential for long-term, quarterly extensions

Start Date: ASAP

About the Role:

Medasource is seeking an experienced Clinical Appeals Registered Nurse (RN) to support the Medicare appeals team for one of our leading healthcare insurance clients. This fully remote opportunity focuses on reviewing clinical appeals, evaluating medical necessity, and ensuring accurate, timely determinations in accordance with Medicare guidelines and regulatory requirements.

The ideal candidate will have direct Medicare clinical appeals experience, a strong understanding of utilization review and medical necessity criteria, and the ability to work independently in a fast-paced environment. This position offers the potential for long-term contract extensions while supporting a growing clinical appeals team.

What You’ll Do

• Review and process Medicare clinical appeals submitted by members and providers within required timeframes.
• Evaluate denied claims, clinical documentation, and medical necessity criteria to support accurate appeal determinations.
• Handle inpatient and outpatient appeals, including expedited requests, radiology, and DME denials.
• Apply Medicare regulations, medical policies, and clinical review guidelines to ensure compliance.
• Prepare appeal determinations, notification letters, and supporting documentation.
• Collaborate with medical directors and internal teams while maintaining accuracy and productivity expectations.

What You Bring

• Active Registered Nurse (RN) license required.
• Direct Medicare clinical appeals experience required.
• Associate degree in Nursing or equivalent relevant education and experience.
• Strong experience with medical necessity reviews, clinical documentation, and appeal determinations.
• Inpatient and outpatient appeals experience preferred.
• Previous payer-side experience with Medicare, Medicaid, or commercial insurance preferred.
• Familiarity with MCG, InterQual, CMS guidelines, or Facets is a plus.
• Strong clinical judgment, written communication, and ability to work independently.

EEO Statement:

Medasource is an equal opportunity employer that does not discriminate on the basis of actual or perceived race, color, creed, religion, national origin, ancestry, citizenship status, age, sex or gender (including pregnancy, childbirth, lactation and related medical conditions), gender identity or gender expression, sexual orientation, marital status, military service and veteran status, physical or mental disability, protected medical condition as defined by applicable state or local law, genetic information, or any other characteristic protected by applicable federal, state, or local laws and Ordinances.

Pay Disclaimer:

The pay range for this job level is a general guideline only and not a guarantee of compensation or salary. Additional factors considered in extending an offer include (but are not limited to) responsibilities of the job, education, experience, knowledge, skills, and abilities, as well as internal equity, alignment with market data, applicable

First wave of applications will be accepted until 10/22