Clinical Appeals RN

**Position:** Clinical Appeals Nurse (Medicare) **Client:** Health Insurance Client **Location:** 100% Remote (EST Hours) **Start Date:** ASAP **Key Responsibilities** * Review and evaluate Medicare appeals cases (pre\-service and post\-service) * Conduct clinical documentation review and apply medical necessity criteria * Draft appeal determinations using standardized templates * Ensure complete and accurate documentation, including attachments * Manage case workload aligned to productivity expectations (\~5/day) * Collaborate with internal teams and perform required outreach as needed * Utilize AI\-assisted tools while maintaining clinical judgment **Top Denial Types / Case Mix** * Pre\-service / expedited appeals (high priority) * Radiology denials * Durable Medical Equipment (DME) * Dual\-eligible / waiver services (e.g., PCS) **Required Qualifications** * Active Registered Nurse (RN) license (compact preferred) * Strong experience in clinical appeals, preferably Medicare * Background in payer\-side utilization management or appeals * Experience with: * GuidingCare (preferred) * Facets (preferred) * Strong clinical documentation and writing skills * High attention to detail (audit\-sensitive environment)