Remote Appeals Nurse Reviewer RN Job Description

Make an Impact in a Role That Matters

Are you a detail-oriented Registered Nurse with a passion for ensuring quality healthcare decisions? Step into the meaningful role of Remote Appeals Nurse Reviewer RN and take charge of shaping better patient outcomes from anywhere. This is your opportunity to contribute to a respected healthcare organization while enjoying the flexibility of working remotely. With a competitive annual salary of $86,480 and the chance to impact lives every day, your skills and experience are truly valued here.

About the Role

As a Remote Appeals Nurse Reviewer RN, you'll be at the forefront of the healthcare appeals process. Your critical thinking, clinical knowledge, and communication skills will help uphold the integrity of care delivery by reviewing appeal cases and medical necessity determinations. Every day, you'll work closely with clinical guidelines, policy interpretations, and healthcare regulations to ensure that members receive fair and accurate evaluations.

Key Responsibilities

• Conduct comprehensive clinical reviews of denied claims and appeals from providers, members, and third-party administrators.
• Analyze medical records, clinical notes, and supporting documentation to evaluate medical necessity.
• Apply clinical guidelines, evidence-based protocols, and utilization management standards to decision-making.
• Collaborate with internal teams, including physicians, compliance officers, and claims examiners, to resolve complex appeal issues.
• Provide written rationales and documentation supporting appeal determinations.
• Participate in peer-to-peer reviews and communicate decisions to healthcare providers in a clear and professional manner.
• Stay up-to-date with changing clinical criteria, regulatory compliance standards, and state-specific review requirements
• Maintain confidentiality, professionalism, and adherence to HIPAA and other applicable healthcare regulations.

What Success Looks Like

This role isn't just about reviewing documentation—it's about improving healthcare delivery through responsible decision-making. Successful Remote Appeals Nurse Reviewers are those who:

• Thrive in an autonomous, structured remote environment
• Bring empathy and objectivity to each case
• Navigate complex clinical records with confidence
• Deliver timely, well-documented, and fair decisions that align with medical guidelines

Work Environment & Culture

You'll be part of a mission-driven team that values accuracy, integrity, and compassion. Collaboration is at the heart of our work culture—even in a remote setting. We use secure cloud platforms, electronic health record systems, and internal portals that facilitate seamless teamwork. Your voice is heard, your work is appreciated, and your growth is encouraged.

Team Collaboration Includes:

• Daily sync-ups with remote team members
• Scheduled case conferences and clinical roundtables
• Virtual knowledge-sharing sessions and workshops

We strive to foster a culture where every nurse feels supported, professionally empowered, and proud of their role in patient care.

Tools and Technology You'll Use

To perform this role effectively, you’ll have access to a suite of advanced tools and secure technology platforms:

• Electronic Medical Record (EMR) systems
• Appeals case management software
• ICD-10 and CPT coding databases
• HIPAA-compliant video conferencing tools
• Clinical guideline resources such as InterQual or MCG
• Internal knowledge base and decision-support tools

These resources ensure accuracy in review processes while providing an intuitive workflow experience.

Skills and Qualifications

Required:

• Active, unrestricted RN license in the U.S.
• Minimum of 3 years of recent clinical experience, preferably in utilization management, case review, or appeals
• In-depth understanding of evidence-based clinical criteria and managed care regulations
• Strong written and verbal communication skills
• Ability to work independently in a structured remote environment
• Familiarity with medical coding, billing processes, and claims review protocols

Preferred:

• Previous experience in a remote nursing role
• Certification in Case Management (CCM) or Utilization Review (UR)
• Multistate licensure or compact state licensure
• Comfort using EMRs, clinical databases, and decision-support software

Career Growth and Learning Opportunities

We believe in investing in our people. As a valued member of our team, you’ll gain access to:

• Continuous training on new clinical guidelines, regulations, and tech tools
• Tuition reimbursement programs for certifications or advanced degrees
• Opportunities to mentor junior reviewers and participate in clinical leadership projects
• Access to leadership development resources and internal mobility pathways

Whether you're looking to deepen your expertise or move into a leadership track, you'll find support every step of the way.

Compensation and Benefits

We offer a competitive compensation package designed to support your health, wellness, and professional goals:

• Annual salary: $86,480
• Health, dental, and vision insurance
• 401(k) with company match
• Generous paid time off and holidays
• Continuing education support
• Remote work stipend and technology support

Your hard work deserves recognition, and our benefits reflect that commitment.

Why Join Us?

This is more than a job. It’s a calling to shape patient care at a systemic level. As a Remote Appeals Nurse Reviewer RN, you’ll ensure patients receive fair treatment, providers are supported, and the healthcare system functions with integrity. Your role directly impacts patient journeys across the country, without requiring you to step foot in a traditional office.

If you’re a compassionate nurse with an analytical mindset and a passion for equitable care, this role is tailored for you.

Your Next Opportunity Starts Here

Take the next step in your career from the comfort of your home. Your clinical expertise and dedication to fair, high-quality care are needed more than ever. Join a forward-thinking healthcare team that recognizes and celebrates your impact.

Your next big opportunity awaits—apply now!