Remote Clinical Appeals RN – Utilization & Policy Expert

The Judge Group; Philadelphia (Philadelphia County); A distancia; USD 85.000 - 110.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical insurance

Dental insurance

Vision insurance

Descripción de la vacante

The Judge Group is seeking a Clinical Appeals Coordinator, RN for a fully remote role restricted to candidates residing in Pennsylvania, New Jersey, or Delaware. This position requires active PA RN licensure, a BSN, and extensive clinical nursing and utilization management experience.

The role involves end-to-end clinical appeals processing across medical necessity, benefit coverage, and related healthcare areas, with rotating Saturday/holiday schedules.

Formación

• Active, unencumbered Pennsylvania RN license or multistate compact license that authorizes practice in Pennsylvania.
• Residence in Pennsylvania, New Jersey, or Delaware.
• Bachelor of Science in Nursing.
• Minimum of five years of clinical nursing experience.
• Experience in utilization management, prior authorization, concurrent review, retrospective review, case management, clinical appeals, grievance and appeals operations, or related managed care operations.
• Demonstrated knowledge of clinical appeal processing, medical necessity review, benefit interpretation, medical policy application, and appeal documentation requirements.

Responsabilidades

• Manage assigned clinical appeals from intake through resolution, including documentation collection, clinical research, outreach, review coordination, determination support, notifications, and implementation of appeal decisions.
• Review appeal files for completeness and accuracy, including denial letters, medical records, benefit provisions, prior authorization history, claims information, medical policies, review criteria, and member or provider submissions.
• Apply clinical nursing knowledge, utilization management principles, benefit language, and evidence-based criteria to support appropriate appeal classification and handling.
• Identify medical necessity, benefit coverage, administrative, pharmacy, behavioral health, and regulatory issues; elevate complex or high-risk cases appropriately.
• Assist Appeals Specialists in identifying the appropriate review level, reviewer qualifications, matched-specialty requirements, and questions for Medical Directors or independent physician consultants.
• Coordinate and document matched-specialty reviews, peer reviews, Medical Director reviews, external review preparation, and committee activities.
• Review investigations, case summaries, outreach records, clinical documentation, and system entries to ensure accuracy, completeness, and compliance with departmental standards.
• Prepare and review clear, accurate, and timely correspondence for members, providers, authorized representatives, and other stakeholders.
• Review Level 1 and Level 2 case summaries before committee meetings to ensure clinical issues, appeal rationale, benefit provisions, medical policies, and reviewer questions are clearly presented.
• Monitor case status and appeal inventory to meet applicable state, federal, ERISA, ACA, NCQA, client, and internal turnaround-time requirements.
• Maintain audit-ready files documenting the appeal, investigation, clinical and benefit review, applicable criteria, reviewer involvement, determination rationale, and required notifications.
• Collaborate with Compliance, Medical Directors, Utilization Management, Care Management, Claims, Provider Relations, and other business areas to resolve appeal-related issues.
• Support policy, procedure, workflow, system, regulatory, and accreditation changes affecting clinical appeals.
• Identify recurring appeal issues, documentation gaps, and opportunities for process improvement, quality improvement, provider education, and utilization management feedback.
• Participate in training, calibration, quality reviews, audit preparation, and continuous improvement activities while maintaining privacy and confidentiality requirements.

Conocimientos

RN license

Clinical nursing

Utilization management

Communication

Educación

BSN

Herramientas

Microsoft Office

Descripción del empleo

The Judge Group is seeking a Clinical Appeals Coordinator, RN for a fully remote role restricted to candidates residing in Pennsylvania, New Jersey, or Delaware. This position requires active PA RN licensure, a BSN, and extensive clinical nursing and utilization management experience.

The role involves end-to-end clinical appeals processing across medical necessity, benefit coverage, and related healthcare areas, with rotating Saturday/holiday schedules.