Clinical Appeals RN

Intepros; Philadelphia (Philadelphia County); Remote; USD 80,000 - 110,000; Full time

Job summary

Intepros is seeking a Clinical Appeals Coordinator to apply clinical nursing judgment, utilization management knowledge, and evidence-based criteria to support appeal determinations. This role serves as a clinical resource to Appeals Specialists, Medical Directors, peer reviewers, and cross-functional teams.

The ideal candidate holds an active Pennsylvania RN license (or compact license including PA), with at least 5 years in clinical nursing or managed care, and experience with NCQA, InterQual,

Qualifications

• Active, unrestricted Pennsylvania RN license or compact RN license that includes Pennsylvania.
• Minimum of 5 years of clinical nursing or comparable healthcare experience.
• Experience in utilization management, utilization review, prior authorization, concurrent or retrospective review, case management, clinical appeals, grievances and appeals, or related managed care operations.
• Strong ability to review medical records and evaluate medical necessity, denial rationale, benefit language, medical policy, and clinical documentation.
• Knowledge of clinical appeal processes and regulatory requirements.
• Understanding of NCQA standards and state/federal appeal requirements.
• Strong clinical judgment, critical-thinking, analytical, and problem-solving skills.
• Excellent written and verbal communication skills, including the ability to prepare accurate member- and provider-facing documentation.
• Ability to independently manage multiple cases, competing priorities, and regulatory deadlines.
• Strong attention to detail with a focus on documentation quality, compliance, member advocacy, and audit readiness.
• Proficiency with Microsoft Office and experience working with healthcare, clinical documentation, claims, utilization management, or appeal systems.

Responsibilities

• Manage assigned clinical appeals from intake through resolution, including clinical review, documentation gathering, outreach, research, reviewer coordination, determination support, and case completion.
• Review medical records, denial letters, benefit information, prior authorization history, claims information, medical policies, clinical criteria, and provider or member documentation.
• Apply clinical nursing judgment, utilization management principles, medical policy, benefit language, and evidence-based criteria to support accurate appeal handling.
• Evaluate appeals involving medical necessity, benefit coverage, pharmacy, behavioral health, administrative, or regulatory issues and elevate complex cases when appropriate.
• Coordinate Medical Director, peer, matched-specialty, independent, and committee reviews as required.
• Support Appeals Specialists in determining the appropriate level of review, reviewer qualifications, and clinical questions requiring physician review.
• Review appeal investigations, case summaries, clinical documentation, member/provider contacts, and system entries for accuracy and completeness.
• Prepare and review clear, accurate, and timely correspondence to members, providers, and authorized representatives.
• Review Level 1 and Level 2 case summaries and ensure appeal rationale, clinical issues, benefit provisions, medical policies, and reviewer questions are clearly documented.
• Ensure appeals are completed within applicable state, federal, ERISA, ACA, NCQA, client, and internal turnaround-time requirements.
• Maintain complete, accurate, and audit-ready appeal files documenting the investigation, clinical review, applicable criteria, reviewer involvement, determination rationale, and required notifications.
• Collaborate with Medical Directors, Utilization Management, Care Management, Claims, Compliance, Provider Relations, Quality, and other business areas.
• Identify appeal trends, documentation gaps, recurring issues, and opportunities for quality or process improvement.
• Participate in training, quality reviews, audit preparation, policy updates, calibration activities, and continuous improvement initiatives.

Skills

Clinical nursing judgment

Utilization management

NCQA/state/federal requirements

InterQual/MCG criteria

Education

Active RN license

BSN (preferred)

Tools

InterQual

MCG

Job description

Location: Fully Remote - Must reside in Pennsylvania, New Jersey, or Delaware

Licensure: Active Pennsylvania RN license or Nurse Licensure Compact license that includes Pennsylvania

Position Overview

The Clinical Appeals Coordinator will apply clinical nursing judgment, utilization management knowledge, benefit interpretation, medical policy, and evidence-based criteria to support appeal determinations. This individual will also serve as a clinical resource to Appeals Specialists, Medical Directors, peer reviewers, and cross-functional teams. The ideal candidate will have a strong background in utilization management and/or clinical appeals, knowledge of NCQA and state/federal appeal requirements, and experience applying clinical review criteria such as InterQual or MCG.

Key Responsibilities

• Manage assigned clinical appeals from intake through resolution, including clinical review, documentation gathering, outreach, research, reviewer coordination, determination support, and case completion.
• Review medical records, denial letters, benefit information, prior authorization history, claims information, medical policies, clinical criteria, and provider or member documentation.
• Apply clinical nursing judgment, utilization management principles, medical policy, benefit language, and evidence-based criteria to support accurate appeal handling.
• Evaluate appeals involving medical necessity, benefit coverage, pharmacy, behavioral health, administrative, or regulatory issues and elevate complex cases when appropriate.
• Coordinate Medical Director, peer, matched-specialty, independent, and committee reviews as required.
• Support Appeals Specialists in determining the appropriate level of review, reviewer qualifications, and clinical questions requiring physician review.
• Review appeal investigations, case summaries, clinical documentation, member/provider contacts, and system entries for accuracy and completeness.
• Prepare and review clear, accurate, and timely correspondence to members, providers, and authorized representatives.
• Review Level 1 and Level 2 case summaries and ensure appeal rationale, clinical issues, benefit provisions, medical policies, and reviewer questions are clearly documented.
• Ensure appeals are completed within applicable state, federal, ERISA, ACA, NCQA, client, and internal turnaround-time requirements.
• Maintain complete, accurate, and audit-ready appeal files documenting the investigation, clinical review, applicable criteria, reviewer involvement, determination rationale, and required notifications.
• Collaborate with Medical Directors, Utilization Management, Care Management, Claims, Compliance, Provider Relations, Quality, and other business areas.
• Identify appeal trends, documentation gaps, recurring issues, and opportunities for quality or process improvement.
• Participate in training, quality reviews, audit preparation, policy updates, calibration activities, and continuous improvement initiatives.

Required Qualifications

• Active, unrestricted Pennsylvania RN license or compact RN license that includes Pennsylvania.
• Minimum of 5 years of clinical nursing or comparable healthcare experience.
• Experience in utilization management, utilization review, prior authorization, concurrent or retrospective review, case management, clinical appeals, grievances and appeals, or related managed care operations.
• Strong ability to review medical records and evaluate medical necessity, denial rationale, benefit language, medical policy, and clinical documentation.
• Knowledge of clinical appeal processes and regulatory requirements.
• Understanding of NCQA standards and state/federal appeal requirements.
• Strong clinical judgment, critical-thinking, analytical, and problem-solving skills.
• Excellent written and verbal communication skills, including the ability to prepare accurate member- and provider-facing documentation.
• Ability to independently manage multiple cases, competing priorities, and regulatory deadlines.
• Strong attention to detail with a focus on documentation quality, compliance, member advocacy, and audit readiness.
• Proficiency with Microsoft Office and experience working with healthcare, clinical documentation, claims, utilization management, or appeal systems.

Preferred Qualifications

• Bachelor of Science in Nursing (BSN).
• Previous experience within a health plan, managed care organization, TPA, utilization management organization, or delegated clinical review environment.
• Experience with InterQual and/or MCG clinical criteria.
• Knowledge of CMS guidance, evidence-based clinical guidelines, medical policies, and plan-specific criteria.
• Experience with NCQA, Department of Insurance, internal quality, client, or regulatory audits.
• Experience handling complex medical necessity, expedited, external review, pharmacy, behavioral health, or benefit appeals.
• Familiarity with Medicare, Medicaid, Commercial, Exchange, ERISA, ACA, and state-specific appeal requirements.
• Experience collaborating with Medical Directors, physician reviewers, Compliance, Utilization Management, Care Management, Claims, Provider Relations, and Quality teams.
• Experience identifying appeal trends, overturn drivers, documentation gaps, or process improvement opportunities.