Appeals Nurse Consultant

Responsibilities

We are representing a confidential healthcare organization seeking an Appeals Nurse Consultant to work remotely from Ohio. In this role, you will administer the review and resolution of clinical complaints and appeals for integrated Medicare and Medicaid plans. You will interpret clinical records and apply appropriate criteria and policies in compliance with regulatory and accreditation requirements.

Your day-to-day responsibilities include:

• Implementing best-in-class policies, plans, and procedures to support appeals area objectives
• Executing comprehensive reviews of all clinical and benefit documentation for complaint and appeal requests
• Developing review strategies to ensure cases are overseen by practitioners with relevant clinical expertise
• Applying advanced knowledge of delegation arrangements, coding logic, contracts, clinical criteria, benefit plan structure, and regulatory requirements
• Ensuring appeal process compliance with regulatory and accreditation standards
• Counseling members, representatives, providers, regulators, and participants on the appeals process in compliance with state regulations and benefit plan designs
• Coaching and training junior colleagues in techniques, processes, and responsibilities

What We're Looking For

Required Qualifications:

• Active and unrestricted Registered Nurse (RN) License in your state of residence
• Willingness to obtain a Compact Registered Nurse (RN) License within 3 months of hire
• 3+ years of Medicare/Medicaid Appeal Processing/Review Experience
• Associate's Degree in Nursing OR Nursing Diploma

Preferred Qualifications:

• Bachelor's Degree
• Utilization management or appeals experience

Technical Requirements:

• Direct/hardwired internet connection to a modem/router within 7 feet of your computer with minimum download speed of 25 mbps and 3 mbps upload (WiFi and satellite internet are not permitted)
• Quiet, secure, and private designated home virtual work location that is HIPAA-compliant
• Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously
• Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or similar tools
• Ability to troubleshoot common technical issues independently

How We Work with You

Our talent team at Get A Job.ai partners with leading healthcare organizations to connect qualified professionals with confidential opportunities. When you apply through our platform, a dedicated recruiter will screen your application and guide you through the process. If there's a strong match, we will submit your profile to our client for consideration. Please do not contact the client directly—we will manage all communication and coordination on your behalf to ensure a smooth and professional experience.

Pay

This is a full-time, remote position offering 40 hours per week. Pay details will be discussed with qualified candidates during the screening process.

Equal Employment Opportunity: Get A Job.ai is committed to creating a diverse and inclusive environment. We welcome applications from all qualified candidates regardless of race, color, religion, sex, national origin, age, disability, veteran status, or any other legally protected characteristic.