Remote Clinical Appeals RN - Utilization Management

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

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,