Job Title: RN Appeals Reviewer
Pay Rate: $40/hr (Paid Weekly)
Address: Remote
Allmed Benefits: Vision Insurance, Health Insurance, Dental Insurance, and 401(k)
Contract: 01/19/2026 to 04/17/2026
Position Overview
We are seeking a dedicated and experienced RN Appeals Reviewer to join our team. The ideal candidate will be responsible for conducting comprehensive reviews of member and provider appeals, ensuring all decisions align with organizational policies, benefit plans, regulatory requirements, and clinical criteria. This role requires strong clinical judgment, analytical skills, and the ability to balance accuracy with productivity expectations.
Key Responsibilities
Conduct detailed reviews of member and provider appeals, including clinical documentation and supporting materials.
Analyze claim adjustments, claim histories, and previous determinations to ensure consistency and accuracy.
Evaluate denied services in accordance with policies, benefit plans, state and federal regulations, and evidence-based clinical guidelines.
Render approvals when criteria are met and ensure all determinations are thoroughly documented.
Summarize complex medical information for escalation and review by the Medical Director, as needed.
Maintain a high standard of quality while meeting established production and timeliness goals.
Ensure all work adheres to compliance standards, confidentiality requirements, and organizational procedures.
Qualifications
Active and unrestricted Registered Nurse (RN) license.
Demonstrated experience in appeals review, reconsideration review, or similar clinical review functions.
Strong knowledge of medical terminology, clinical review processes, and health plan operations.
Experience with utilization review or clinical claims review is preferred.
Excellent analytical, critical thinking, and written communication skills.
Ability to work independently while maintaining accuracy and efficiency.