Appeals Nurse (Registered Nurse) – Remote (New York RN License Required) Position Summary We are seeking a dedicated and detail-oriented Appeals Nurse (RN) to join our team in a fully remote capacity. This role supports State and Federal Independent Dispute Resolution (IDR) programs through comprehensive clinical review and appeal determinations. The Appeals Nurse will perform clinical-level reviews, prior authorization assessments, and disputed benefits evaluations while collaborating closely with Medical Review Analysts and Physician Consultants to ensure accurate, timely, and compliant case outcomes. This is a remote position; however, candidates must possess and maintain an active, unrestricted New York State Registered Nurse (RN) license. The ideal candidate is an experienced Registered Nurse with strong clinical judgment, exceptional analytical skills, and the ability to thrive in a collaborative, fast-paced virtual environment.

Key Responsibilities

• Conduct clinical reviews through the appeal level, including chart screening, prior authorization reviews, and disputed benefits evaluations.
• Compile applicable regulatory guidance and research payer-specific requirements to support accurate case determinations.
• Complete electronic review worksheets and prepare well-documented final determinations.
• Assess and adjudicate healthcare claims in accordance with established guidelines and regulatory standards.
• Serve as a clinical resource for administrative and clinical staff by providing guidance, problem-solving assistance, and clarification of review determinations.
• Provide technical support and actively participate in team huddles and collaborative discussions.
• Train and mentor newly hired Registered Nurses as the project and team continues to expand.
• Participate in collaborative training initiatives and ongoing quality improvement efforts.
• Work closely with Medical Review Analysts, Physician Consultants, and interdisciplinary teams to facilitate efficient case resolution.
• Perform additional duties and special projects as assigned.

Required Qualifications

• Active, unrestricted New York State Registered Nurse (RN) license required.
• Bachelor's Degree in Nursing (BSN) or graduation from an approved Registered Professional Nursing program required.
• Minimum of 2 years of recent clinical nursing experience in a healthcare setting.
• Knowledge of and experience with electronic medical record (EMR) systems.
• Strong clinical assessment, analytical, and critical thinking skills.
• Excellent written and verbal communication skills.
• Ability to collaborate effectively with medical, analytical, and administrative support teams.
• Ability to work independently with minimal supervision in a remote environment.
• Strong organizational skills with the ability to manage multiple priorities and meet deadlines in a fast-paced, time-sensitive setting.
• Flexible, innovative, and solution-oriented approach to problem-solving.

Preferred Qualifications

• Experience with appeals, prior authorizations, utilization review, claims adjudication, or Independent Dispute Resolution (IDR).
• Familiarity with state and federal healthcare regulations and payer guidelines.
• Previous experience mentoring or training nursing staff.

Why Join Our Team? Enjoy the flexibility of a fully remote position while leveraging your clinical expertise to support fair and accurate healthcare appeal determinations. As an Appeals Nurse, you'll play a vital role in ensuring quality outcomes while collaborating with a multidisciplinary team dedicated to excellence and regulatory compliance.