Remote Utilization RN — Appeals & Grievances (Contract)

Wellframe; United States; Remote; USD 62,000 - 96,000; Full time

Job summary

HealthEdge is seeking a Temporary A&G RN to independently process transactions and clarify complex items while ensuring output quality and adherence to SLA targets.

You will investigate grievances, perform medical necessity reviews across care settings, and prepare documentation for appeals in line with NCQA standards. Remote work from the US is supported, with potential weekend hours as needed.

Qualifications

• Unrestricted USRN mainland license.
• 2+ years of utilization management experience.
• Experience with medical necessity reviews and appeals.

Responsibilities

• Investigate and process complex grievances and appeals requests from members and providers.
• Perform reviews of inpatient, outpatient, ambulatory and ancillary services for medical necessity.
• Review, research, and prepare documentation related to appeals and grievances in line with NCQA standards.
• Prepare recommendations to uphold or deny appeals and coordinate with Medical Director.
• Document appeal/grievance information on tracking systems.
• Generate written correspondence to providers, members, and regulatory entities.
• Serve as subject matter expert for appeals, grievances, and quality of care issues.
• Support with or perform other essential functions as required.

Skills

Communication skills

Customer service

Clinical guidelines

Accreditation standards

Problem-solving

Team flexibility

Education

Unrestricted USRN mainland license

Tools

MS Office

Job description

HealthEdge is seeking a Temporary A&G RN to independently process transactions and clarify complex items while ensuring output quality and adherence to SLA targets.

You will investigate grievances, perform medical necessity reviews across care settings, and prepare documentation for appeals in line with NCQA standards. Remote work from the US is supported, with potential weekend hours as needed.