Job Title: Appeals Clinical ReviewerJob Description
The Appeals Clinical Reviewer serves as an Appeals Utilization Review Nurse responsible for reviewing and evaluating member and provider appeals related to medical necessity determinations, authorization decisions, and claims outcomes. This role applies clinical expertise, evidence-based guidelines, regulatory requirements, and internal policies to ensure appeal determinations are fair, timely, and compliant. The nurse collaborates closely with Medical Directors, providers, claims teams, and utilization management staff to support high-quality patient care while promoting appropriate utilization of healthcare services. This is a remote opportunity with potential for permanent placement.
Responsibilities

+ Review and evaluate member and provider appeals related to medical necessity determinations, authorization decisions, and claims outcomes.

+ Apply clinical expertise and evidence-based guidelines to assess the...