Remote Appeals Nurse Reviewer

About the Role

Are you a seasoned nursing professional with a meticulous eye for detail and a passion for advocating patient care through fair clinical evaluations? This fully remote Appeals Nurse Reviewer position offers an ideal opportunity to bring your clinical expertise to a dynamic, fast-paced environment where you play a vital role in healthcare quality and compliance. This role is perfect for individuals who are organized, methodical, and thrive in a structured work setting while enjoying the flexibility of remote work.

As an Appeals Nurse Reviewer, you will be responsible for conducting objective, evidence-based reviews of clinical appeals, ensuring all decisions are accurate, timely, and aligned with medical guidelines. If you take pride in helping healthcare systems operate ethically and fairly, this is your opportunity to make a measurable impact from the comfort of your home.

Key Responsibilities

• Evaluate medical necessity and appropriateness of services requested in appeals.
• Review medical records and supporting documentation to determine alignment with clinical policies.
• Render decisions on pre-service, concurrent, and post-service appeals following industry standards.
• Compose clear, defensible clinical rationales and documentation for each case.
• Collaborate with internal medical directors, legal teams, and case managers as needed.
• Identify trends in appeals that may indicate systemic issues or opportunities for quality improvement.
• Ensure strict adherence to applicable regulations, timelines, and compliance standards.
• Maintain current knowledge of clinical guidelines and evidence-based practices.
• Use professional judgment to make fair and defensible determinations.
• Participate in internal audits and quality assurance activities as assigned.

Work Environment

• 100% remote position with no travel required.
• Flexible yet structured schedule to support work-life balance.
• Collaborative virtual team culture with open communication and support.
• Performance-driven environment emphasizing accuracy, timeliness, and compliance.
• Regular video calls and chat-based check-ins for continuous engagement.

Tools and Technology

• Electronic Medical Record (EMR) systems for reviewing case documentation.
• Clinical decision support software for streamlined assessments.
• HIPAA-compliant platforms for secure data handling and communication.
• Communication tools such as Microsoft Teams, Zoom, and Slack are used for real-time collaboration.
• Proprietary case management software tailored for appeals workflows.

Required Qualifications

• Active and unrestricted RN license in any U.S. state.
• Minimum of 3 years clinical experience in acute care, utilization management, or case review.
• Prior experience in appeals, utilization review, or care coordination is highly preferred.
• Strong analytical skills and clinical judgment.
• Ability to interpret and apply clinical guidelines effectively.
• Exceptional written communication for documenting rationales.
• Comfortable navigating and using multiple healthcare IT systems.
• Organized and detail-oriented with a strong focus on meeting deadlines.

Preferred Competencies

• Knowledge of URAC and NCQA standards.
• Experience with managed care or payer-side operations.
• Certification in Utilization Review or Case Management (e.g., CCM, URAC).
• Bilingual capabilities are a plus, but not required.

Why This Role Matters

In this role, your work directly supports ethical healthcare decisions by providing clarity and fairness to appeal cases. You’ll help ensure patients receive appropriate care and that healthcare providers meet compliance standards. By championing clinical integrity and consistency, you contribute to improved health outcomes and increased transparency throughout the healthcare ecosystem.

Compensation and Benefits

• Annual salary: $86,440
• Competitive benefits package including health, dental, vision, and retirement plans
• Generous paid time off and holiday schedule
• Continuing education and professional development support
• Equipment and secure technology tools are provided for a remote setup
• Opportunity to work from anywhere in the U.S.

Career Path and Advancement

This position offers clear pathways for professional growth:

• Advancement into senior-level nurse reviewer roles
• Transition to clinical quality manager or compliance leadership
• Opportunities to participate in quality improvement projects
• Access to specialized training in healthcare law, ethics, and policy

Join a Team That Values Excellence

You’ll be part of a team that is mission-driven, transparent, and deeply committed to improving healthcare processes. We celebrate professionals who bring integrity, accuracy, and compassion to their work. We understand the demands of the nursing profession and honor your dedication by providing a supportive and empowering remote work culture.

Apply Now and Make Your Impact

If you're ready to take your nursing expertise to a new level and make a tangible difference in the healthcare system, all while working from the comfort of your home, then we invite you to apply today.

Shape the standards. Protect the process. Review with purpose.