Schedule: Monday-Friday, 7:30 AM-4:00 PM or 8:00 AM-4:30 PM, with occasional rotating Saturday and holiday coverage.
Position Summary
We are seeking experienced Registered Nurses to join our Clinical Appeals team. In this role, you will support the review and resolution of clinical appeals by applying clinical judgment, utilization management knowledge, benefit interpretation, and evidence-based review criteria. This position plays a key role in ensuring appeals are processed accurately, efficiently, and in compliance with regulatory standards.
Top Skills Should You Possess:
- RN
- Review and manage clinical appeals from intake through final resolution.
- Evaluate medical records, benefit information, prior authorizations, denial rationale, and supporting clinical documentation.
- Apply clinical nursing knowledge and utilization management principles to support appeal determinations.
- Coordinate with Medical Directors, physician reviewers, and cross-functional teams on complex cases.
- Prepare case summaries and ensure all appeal documentation is complete and audit-ready.
- Support member and provider communications related to appeal outcomes.
- Monitor appeal timelines to ensure compliance with state, federal, and accreditation requirements.
- Identify trends, process improvements, and quality enhancement opportunities.
- Participate in training, audits, calibration sessions, and continuous improvement initiatives.
- Active Registered Nurse (RN) license; Pennsylvania RN license (or compact license that includes PA eligibility) required.
- Minimum of 5 years of clinical nursing experience.
- Experience in one or more of the following:
- Utilization Management
- Prior Authorization
- Concurrent or Retrospective Review
- Case Management
- Appeals and Grievances
- Managed Care Operations
- Strong knowledge of medical necessity review, benefit interpretation, and clinical documentation.
- Ability to review medical records and apply evidence-based criteria.
- Excellent written and verbal communication skills.
- Strong critical thinking, analytical, organizational, and time-management skills.
- Proficiency with Microsoft Office and healthcare management systems.
- Bachelor of Science in Nursing (BSN).
- Health plan or managed care experience.
- Experience with NCQA standards and accreditation requirements.
- Familiarity with InterQual, MCG, CMS guidelines, and medical policy review.
- Experience supporting Medicare, Medicaid, Commercial, or ACA appeals.
- Audit, quality review, or regulatory compliance experience.
What’s In It for You?
- Weekends and holidays off
- Join Yoh’s extensive talent community that will provide you with access to Yoh’s vast network of opportunities.
- Direct deposit & weekly epayroll
Estimated Min Rate: $31.50
Estimated Max Rate: $45.00
What’s In It for You?
We welcome you to be a part of the largest and legendary global staffing companies to meet your career aspirations. Yoh’s network of client companies has been employing professionals like you for over 65 years in the U.S., UK and Canada. Join Yoh’s extensive talent community that will provide you with access to Yoh’s vast network of opportunities and gain access to this exclusive opportunity available to you. Benefit eligibility is in accordance with applicable laws and client requirements. Benefits include:
- Medical, Prescription, Dental & Vision Benefits (for employees working 20+ hours per week)
- Health Savings Account (HSA) (for employees working 20+ hours per week)
- Life & Disability Insurance (for employees working 20+ hours per week)
- MetLife Voluntary Benefits
- Employee Assistance Program (EAP)
- 401K Retirement Savings Plan
- Direct Deposit & weekly epayroll
- Referral Bonus Programs
- Certification and training opportunities
Note: Any pay ranges displayed are estimations. Actual pay is determined by an applicant's experience, technical expertise, and other qualifications as listed in the job description. All qualified applicants are welcome to apply.
Yoh, a Day & Zimmermann company, is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
Visit https://www.yoh.com/applicants-with-disabilities to contact us if you are an individual with a disability and require accommodation in the application process.
For California applicants, qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. All of the material job duties described in this posting are job duties for which a criminal history may have a direct, adverse, and negative relationship potentially resulting in the withdrawal of a conditional offer of employment.
It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.
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