Remote - FL
Target start Date : 10/05/2026
Duration: 7 months with possibility to extend
Schedule: M-F: 9am -6pm EST (Possible weekends Saturdays - same as weekday schedule) Not required. No OT
Receive assignments electronically via company applications and excel sheets, emails are also sometimes used for case communication.Review appeal requests, medical records, and apply applicable medical necessity criteria.Write up the appeal clinical review and forward to MD for review and final determination.Receive the case back post MD review for clinical closure and route to coordinator for case closure.
- 4-8 complete cases per day.
- Ability to work remotely and self-directed to keep oneself at pace.Able to use clinical knowledge and experience to visualize the appeal request and get better understanding of clinical picture.
Candidate Requirements
Required: Nursing certification/degree
Preferred:
Required: RN or LPN FL Licensure Required
Preferred: N/A
Years of experience required: At least 3 years in a clinical setting followed by at least 1 year experience in managed care/ utilization management setting such as prior authorization clinical reviewer; appeals clinical reviewer a plus/preferred.
Disqualifiers: Less than 1 year or no managed care / utilization management experience.
Additional qualities to look for: Experience using InterQual criteria application, Also, candidate who in addition to clinical physical health experience has experience in clinical mental health care.
- Top 3 must-have hard skills stack-ranked by importance
1
Clinical utilization management experience – clinical reviews
2
InterQual criteria application
3
Able to work independently
Seeking LPNs or RNs with experience in Utilization Management, Prior Auth, or Appeals medical necessity criteria application in InterQual System.
Preferred candidates that can work later shifts or weekends, once trained, but not required. However, some weekend work may be needed from time to time.
Also, candidates with a behavioral health background a plus but also not required.
