Appeals Registered Nurse

Job Title: Appeals Registered Nurse Location: Remote – California Work Arrangement: Remote Employment Type: Contract-to-Hire Duration: 6+ Months Domain: Managed Care / Utilization Management / Appeals & Grievances Pay Rate: $45.00 - $55.00/hr. on W2 Schedule: Monday – Friday | 9:00 AM – 5:00 PM Deadline: 7/15/2026 Skills Required Primary (Must-Have): Active California Registered Nurse (RN) License Minimum 2 years of Managed Care experience Minimum 2 years of Acute Care or Sub-Acute Nursing experience Experience with Medical Necessity Review and Utilization Management Experience reviewing Commercial and Medicare benefits Prior Authorization experience Pre-service and Post-service review experience Knowledge of MCG (Milliman Care Guidelines) Knowledge of National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) Experience conducting medical record reviews and medical necessity determinations Strong analytical and clinical assessment skills Excellent written and verbal communication skills Proficiency with Microsoft Office Suite, Excel, Adobe PDF, Teams, SharePoint, and shared drives Ability to work independently and collaboratively within a team environment Secondary (Good to Have): Appeals and Grievance Nursing experience Clinical Denials Management experience Utilization Review Nursing experience Knowledge of NCQA, CMS, DMHC, and DHCS regulations Experience working in fast-paced managed care environments Bachelor's Degree in Nursing (BSN) Position Overview The Appeals Registered Nurse is responsible for reviewing and processing member-generated appeals, grievances, and clinical determinations for Commercial and Medicare members. This role involves extensive medical record review, application of medical necessity criteria, and collaboration with Medical Directors and cross-functional teams to ensure accurate and timely determinations while maintaining regulatory compliance. Roles & Responsibilities Review and process first-level clinical appeals and grievances for Commercial and Medicare members Conduct comprehensive medical record reviews and evaluate supporting clinical documentation Analyze pre-service and post-service appeals involving medical necessity, benefit determinations, coding accuracy, and medical policy compliance Prepare accurate and well-supported clinical determination documentation Apply MCG, NCD, LCD, NCCN, ACOG, and other nationally recognized clinical guidelines Evaluate services for medical necessity and coverage eligibility Identify discrepancies and inaccuracies in medical records and clinical documentation Ensure compliance with company policies, accreditation requirements, and regulatory standards Collaborate with Medical Directors on complex appeal cases Partner with Utilization Management, Pharmacy, Claims, Customer Service, Quality, and Care Management teams Communicate appeal outcomes and required follow-up actions Participate in clinical discussions to ensure consistency in decision-making Maintain compliance with NCQA, CMS, DMHC, DHCS, and organizational requirements Meet regulatory turnaround times and service level expectations Support quality improvement initiatives related to appeals and utilization management processes Maintain accurate documentation and case records Perform additional duties as assigned Minimum Qualifications Associate Degree in Nursing (ADN) required Active California Registered Nurse (RN) License required Minimum 2 years of Managed Care experience Minimum 2 years of Acute Care or Sub-Acute Clinical Nursing experience Experience with Medical Necessity Review and Utilization Management Experience reviewing Commercial and Medicare benefits Prior Authorization experience Experience with pre-service and post-service reviews Strong analytical, documentation, and communication skills Preferred Qualifications Bachelor of Science in Nursing (BSN) Appeals & Grievance Nursing experience Clinical Denials Management experience Utilization Review Nursing experience Knowledge of NCQA, CMS, DMHC, and DHCS regulations Experience working in managed care environments Strong clinical assessment and decision-making skills Work Environment Fully remote position within California Fast-paced managed care environment Extensive medical record review and documentation responsibilities Frequent collaboration with Medical Directors and cross-functional teams Independent work with strong emphasis on quality, compliance, and regulatory timelines Benefits Medical | Dental | Vision | 401(k) | Paid Sick Leave EEOC Compliance We are an equal opportunity employer, and all qualified applicants will receive consideration for employment. Disclaimer AI Usage Policy: Pacer Group uses AI to assist in screening applications. Final hiring decisions are made by human recruiters based on qualifications and experience. Show more Show less