• Adecco Healthcare & Life Sciences
• is partnering with our client to hire an experienced
• Utilization Management Appeals Nurse
• for a fully remote opportunity. This position is ideal for an experienced RN with strong clinical knowledge, excellent writing skills, and the ability to review complex medical records and develop well-supported clinical appeals.
• Job Summary / Purpose
• The
• Appeals Nurse
• is part of a dynamic team responsible for crafting strongly defensible appeals by leveraging critical-thinking skills and conducting thorough reviews of denial documents and medical records on behalf of provider clients.

The Appeals Nurse uses their clinical experience to perform medical record reviews, extract pertinent clinical information, and support the development of appeal letters while maintaining high standards for quality and efficiency. The role requires the use of clinical data, nationally recognized guidelines, and appropriate medical literature to support accurate and defensible clinical appeals. The successful candidate is self-directed, motivated, and able to work independently in a fast-paced, continuously evolving environment. The Appeals Nurse collaborates closely with physicians, operations, intake, leadership, and other departments and works directly with the Appeals leadership and team.

• Job Responsibilities
• + Accurately and efficiently review patient medical records and extract pertinent clinical information.

+ Review denial documentation and identify key clinical details necessary to support an appeal.

+ Compose clear, concise, and strongly defensible appeal letters in accordance with established processes and department/company guidelines.

+ Incorporate appropriate clinical data, medical literature, national criteria, and evidence-based guidelines into appeal letters.

+ Utilize approved appeal tools, templates, and resources to ensure consistency and quality.

+ Ensure appeal letters demonstrate appropriate clinical rationale and accurately support the requested determination.

+ Complete assigned cases within established turnaround-time expectations while maintaining a high level of quality.

+ Apply strong clinical judgment and critical-thinking skills when evaluating medical records and denial rationale.

+ Adhere to Optum and OPAS policies, procedures, and department guidelines.

+ Maintain accurate timekeeping and follow established procedures for schedule changes and time-off requests.

+ Arrive on time and adhere to the approved work schedule.

+ Work independently while collaborating effectively with physicians, operations, intake, leadership, and other departments.

+ Maintain excellent written communication, grammar, organization, and attention to detail.

+ Adapt to a fast-paced and continuously evolving work environment.

• Position Details
• Pay Rate:
• $37.50/hour (39.25/hour)
• Work Arrangement:
• 100% Remote
• Schedule:
• Monday-Friday, 8-hour shifts
• Hours:
• Schedule will fall between
• 6:00 AM and 6:00 PM EST
• Required Qualifications
• + Active
• Registered Nurse (RN) license
• + Minimum
• 3 years of bedside RN experience
• + Recent experience in an
• adult Emergency Department (ED), Telemetry, ICU, or CCU
• setting + Excellent written communication and professional writing skills + Strong clinical judgment and critical-thinking abilities + Strong medical record review and clinical documentation skills + Proficiency with
• Microsoft Word
• + Ability to work independently and manage multiple cases in a fast-paced environment + Excellent attention to detail and ability to meet established turnaround times
• Preferred Qualifications
• + Prior
• Utilization Management (UM)
• experience + Previous
• clinical appeals
• experience + Familiarity with
• MCG•and/or •InterQual (IQ) guidelines•+ Experience reviewing medical necessity determinations or insurance denials + Experience incorporating medical literature and evidence-based clinical guidelines into written appeals •

Pay Details:

• $37.

50 per hour Benefit offerings available for our associates include medical, dental, vision, life insurance, short-term disability, additional voluntary benefits, EAP program, commuter benefits and a 401K plan. Our benefit offerings provide employees the flexibility to choose the type of coverage that meets their individual needs. In addition, our associates may be eligible for paid leave including Paid Sick Leave or any other paid leave required by Federal, State, or local law, as well as Holiday pay where applicable. Equal Opportunity Employer/Veterans/Disabled Military connected talent encouraged to apply To read our Candidate Privacy Information Statement, which explains how we will use your information, please navigate to https://www.adecco.com/en-us/candidate-privacy The Company will consider qualified applicants with arrest and conviction records in accordance with federal, state, and local laws and/or security clearance requirements, including, as applicable:

+ The California Fair Chance Act

+ Los Angeles City Fair Chance Ordinance

+ Los Angeles County Fair Chance Ordinance for Employers

+ San Francisco Fair Chance Ordinance

• Massachusetts Candidates Only:
• It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment.

An employer who violates this law shall be subject to criminal penalties and civil liability.