Remote HEDIS RN Appeals Specialist

Actalent; Tampa (FL); Remote; USD 52,000 - 58,000; Full time

Benefits offered by this job

Medical, dental & vision

401(k) Retirement Plan

Remote work options

Job summary

Actalent is hiring multiple RNs for a HEDIS-focused contract role starting in November. Candidates must hold an active RN license and have 3+ seasons of HEDIS experience, with nursing background aligned to medical quality measures. LPNs are not considered for this position.

The role is remote, US-based, with a pay rate of $38–$42 per hour. Responsibilities include reviewing clinical data, preparing case reviews, and producing appeal communications in line with NCQA guidelines.

Qualifications

• Active RN license required.
• Nursing background with exposure to HEDIS and medical quality measures.
• Minimum of 3 seasons of recent HEDIS experience.
• Comfortable working with electronic systems and databases to track appeals and authorizations.

Responsibilities

• Review clinical data and documentation to determine claim payment decisions per NCQA guidelines.
• Evaluate denied claims and decide to overturn or uphold; escalate complex cases to Medical Director.
• Prepare comprehensive case reviews for Medical Director when criteria are not met.
• Generate clear appeal communications to members and providers per NCQA guidelines.
• Create system authorization events when overturned decisions occur.
• Request additional clinical information to facilitate timely appeals resolution.
• Prepare case information for Administrative Law Hearings.
• Maintain NCQA timeframes and accurate tracking in appeals database.
• Assist Medical Director in updating policies to satisfy NCQA standards.
• Apply nursing knowledge and HEDIS measures to support accurate utilization and appeals review.

Skills

Active RN license

HEDIS awareness

3+ seasons HEDIS

Electronic systems & databases

Job description

Actalent is hiring multiple RNs for a HEDIS-focused contract role starting in November. Candidates must hold an active RN license and have 3+ seasons of HEDIS experience, with nursing background aligned to medical quality measures. LPNs are not considered for this position.

The role is remote, US-based, with a pay rate of $38–$42 per hour. Responsibilities include reviewing clinical data, preparing case reviews, and producing appeal communications in line with NCQA guidelines.