State Licensed Clinical Appeals Nurse

Job Summary

Seeking a remote Clinical Appeals Nurse, this long-term contract position requires an active LPN or RN license and focuses on reviewing appeal and dispute documentation, analyzing medical records, and making evidence-based decisions to ensure fair outcomes.

Key responsibilities:

• Analyze medical records and case files to produce clear, objective reconsideration or dispute resolution summaries
• Make evidence-based decisions using independent judgment aligned with legal statutes, regulations, policies, and clinical standards
• Conduct detailed research using federal regulations, medical standards, policy manuals, and clinical literature to support decisions

Required qualifications:

• Associate's degree or higher in a healthcare-related field from an accredited institution
• Active LPN or RN License required
• Minimum of three (3) years' experience in medical appeals, dispute resolution, clinical review, or related healthcare environment
• Background in Nursing, Physical Therapy, Occupational Therapy, or Respiratory Therapy required
• Proven ability to compose or evaluate appeals and payment-related determinations