New

Appeals Nurse

Spectraforce Technologies

United States, North Carolina, Raleigh

500 West Peace Street (Show on map)

Jul 15, 2026

Position Title: Appeals Nurse

Work Location: Remote

Assignment Duration: 1 Year

Work Arrangement: Remote

Responsibilities:

Job Description: Job Summary

Position Purpose: Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met

Education/Experience: LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. Proficient with Microsoft Office applications. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred.

License/Certification: RN or LPN license.

For Fidelis Care only: NYS RN license required.

Responsibilities

* Review clinical data to determine claim payment based on company policies and * National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review * Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received * Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions * Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution * Gather and prepare case information for Administrative Law Hearings * Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database * Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements.