Remote Clinical Appeals Clinician (RN/LPN)

Spectraforce Technologies, Inc.; Raleigh (NC); Remote; USD 34,000 - 52,000; Part time

Job summary

Spectraforce Technologies, Inc. is seeking a part-time Clinical Review Clinician to perform appeals reviews remotely across the US. The role supports the Medicare Appeals department, with a focus on determining medical necessity and aligning with NCQA standards.

Ideal candidates have RN or LPN licensure and 2–4 years of related experience, plus knowledge of NCQA/Medicare regulations and utilization management. Flexible 20-hour weeks are available, with schedule consistency required.

Qualifications

• Requires RN or LPN license with state licensure.
• Knowledge of NCQA, Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.
• Must have Medicare knowledge; InterQual or Milliman experience helpful.
• Retrospective claims clinical reviews experience preferred.
• Not having a valid/active RN/LPN license is a disqualifier.

Responsibilities

• Prepares case reviews for Medical Directors by researching the appeal and analyzing the basis for the appeal.
• Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards.
• Communicates with members, providers, facilities, and other departments regarding appeals requests.
• Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards.
• Works with leadership to increase consistency, efficiency, and appropriateness of responses of all appeals requests.
• Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices.
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

NCQA knowledge

Medicare/Medicaid regulations

Utilization management processes

Education

RN/LPN license

Advanced licenses (LCSW/LMHC/LMFT/LP C/Physician)

Job description

Spectraforce Technologies, Inc. is seeking a part-time Clinical Review Clinician to perform appeals reviews remotely across the US. The role supports the Medicare Appeals department, with a focus on determining medical necessity and aligning with NCQA standards.

Ideal candidates have RN or LPN licensure and 2–4 years of related experience, plus knowledge of NCQA/Medicare regulations and utilization management. Flexible 20-hour weeks are available, with schedule consistency required.