• Clinical Appeals Nurse (RN)

    Molina Healthcare (GA)
    appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously ... For this position we are seeking a (RN) Registered Nurse who must be licensed for the state they...request authorization. Strongly prefer candidates with a background in appeals and grievances. Excellent computer multi-tasking skills and good… more
    Molina Healthcare (08/02/25)
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  • Utilization Management Appeals Registered…

    Emory Healthcare/Emory University (Atlanta, GA)
    …**Description** We're seeking under the direction of the **Utilization Management Appeals Professional, Registered Nurse ** is responsible for managing clinical ... in Administrative Law Judge (ALJ) hearings and if required, Medicare Appeals Council. + Primary duties and responsibilities: Participates in external reviews… more
    Emory Healthcare/Emory University (08/08/25)
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  • Nurse Appeals RN

    Elevance Health (Norfolk, VA)
    ** Nurse Appeals ** **Hybrid 1:** This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing ... employment, unless an accommodation is granted as required by law._ The ** Nurse Appeals ** is responsible for investigating and processing and medical necessity … more
    Elevance Health (08/08/25)
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  • Clinical Appeals Nurse

    Centene Corporation (Columbia, SC)
    …workplace flexibility. **Position Purpose:** Act as the liaison for all statewide appeals , fair hearings, review organizations, and other external type appeals . ... both State and NCQA requirements. + Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of services… more
    Centene Corporation (08/03/25)
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  • Appeals Registered Nurse

    Evolent (Montgomery, AL)
    …Stay for the culture. **What You'll Be Doing:** Job Description The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part ... of a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent… more
    Evolent (08/08/25)
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  • Insurance Specialist-Mount Sinai West-Utilization…

    Mount Sinai Health System (New York, NY)
    …for appeals , On / Off-site Insurance reviews + Implements first step of appeals process to assist Appeals Nurse and Enter Denial information in ... department protocol (IPRO Discharge Appeals / Insurance requests) + Support Appeals Nurse / Manager by confirming status of denials + Tracking status of… more
    Mount Sinai Health System (07/23/25)
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  • Utilization Management RN

    Guidehouse (New York, NY)
    **Job Family** **:** Clinical Appeals Nurse **Travel Required** **:** None **Clearance Required** **:** None **What You Will Do** **:** + Performs chart review ... of identified patients to identify quality, timeliness and appropriateness of patient care + Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self-pay patients, based on appropriate guidelines + Uses these… more
    Guidehouse (07/25/25)
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  • Clinical Manager - Provider Appeals (Hybrid…

    Henry Ford Health System (Troy, MI)
    General Summary: The Clinical Manager, Medical Appeals supports appeals team members to plan, direct, evaluate, coordinate, and manage the activities associated ... with the Medical Appeals as it relates to key HAP initiatives and... and Grievance. Education and Experience Required: + Registered Nurse with current Michigan licensure. + Bachelor's Degree in… more
    Henry Ford Health System (08/07/25)
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  • Appeals Specialist I (Remote)

    CareFirst (Baltimore, MD)
    **Resp & Qualifications** **PURPOSE:** The Appeals Specialist I is responsible for the initial analysis of appeals and/or grievance correspondence, and ... organizing and tracking information to facilitate and expedite processing of appeals and/or grievances received from a variety of sources. **ESSENTIAL FUNCTIONS:**… more
    CareFirst (08/08/25)
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  • Appeals Manager

    BronxCare Health System (Bronx, NY)
    Overview The Appeals Manager is responsible to assist in the analysis and preparation of response to denial notification letters that arrive in letter and electronic ... format. Collaborating with the Department Denial and Appeals Coordinators, Physician Advisors, and the clinical staff, the...electronic database system. The Appeal Manager should be a nurse who has 3-5 years or more of experience… more
    BronxCare Health System (06/21/25)
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