In this fully remote role, the clinician reviews denial documentation and patient medical records to develop clear, evidence-based utilization management appeal letters. The work centers on adult acute care cases and requires strong clinical judgment, concise professional writing, and support for medical necessity determinations using clinical data and published guidelines. The nurse works independently while collaborating with physicians, operations, intake, and leadership to produce accurate appeals within turnaround-time expectations.
Key Responsibilities
- Review patient medical records and extract pertinent clinical information for appeal development.
- Analyze denial documents and identify clinical details needed to support medical necessity arguments.
- Compose clear, concise, and defensible appeal letters using established processes and department guidelines.
- Incorporate clinical data, medical literature, national criteria, and evidence-based guidelines into written appeals.
- Use approved appeal tools, templates, and resources to ensure consistency and quality.
- Coordinate with physicians, operations, intake, leadership, and other departments as needed.
- Complete assigned cases within turnaround-time expectations while maintaining accuracy and attention to detail.
- Work independently in a fast-paced environment and maintain professional documentation standards.
Required
- Active Registered Nurse (RN) license.
- At least 3 years of bedside RN experience.
- Recent experience in an adult Emergency Department, Telemetry, ICU, or CCU setting.
- Strong written communication and professional writing skills.
- Strong clinical judgment, critical-thinking, and medical record review skills.
- Proficiency with Microsoft Word.
Preferred
- Prior utilization management experience.
- Previous clinical appeals experience.
- Familiarity with MCG and/or InterQual guidelines.
- Experience reviewing medical necessity determinations or insurance denials.
- Experience using medical literature and evidence-based guidelines in written appeals.
Benefits & Perks
- 100% remote work arrangement.
- Weekly pay.
- 401(k) plan.
- Medical, dental, and vision benefits.
- Skills training.