Appeals Nurse

Job Title: Clinical Coordinator – Medical

Business Area: Clinical & Care Management

Job Type: Subcon

Location: Remote (Anywhere in Florida)

Duration: 06 Months/Can be Extended

Working hours: Day Shift

Pay Rate: $24 to $25/HR

Job Description:

Position Purpose:

Serve as a clinical resource within the Medical Management team, responsible for reviewing medical documentation and determining the medical necessity of services. This role ensures compliance with InterQual criteria and contract requirements, and facilitates appeal reviews by either approving cases or escalating to a Medical Director.

Key Responsibilities:

• Review all submitted materials including EMRs and supporting documentation to assess completeness and compliance.
• Apply InterQual criteria and contract guidelines to determine medical necessity.
• Make initial determinations on cases; approve or escalate to MD for further review.
• Prepare and submit appeal letters in accordance with NCQA and state regulations.
• Coordinate with internal departments and external review organizations for fair hearings and appeals.
• Maintain accurate logs and documentation for all appeal decisions.
• Stay current with NCQA, CMS, and state regulatory updates.
• Support continuity of care and ensure timely resolution of member and provider inquiries.

Qualifications:

Education/Experience:

• RN with 4+ years of clinical nursing or case management experience OR LPN/LVN with 5+ years of clinical experience
• Managed care or utilization review experience preferred

Licensure/Certification:

• Valid RN, LPN, or LVN license in applicable state
• NCLEX certification and active US RN license preferred for offshore roles

Skills:

• Strong understanding of InterQual and Milliman guidelines
• Familiarity with ICD and CPT codes
• Proficiency in Microsoft Word, Excel, and EMR systems
• Effective communication skills, both verbal and written