HealthEdge · 1 month ago
Appeals RN (Temporary)
United States
Full-time
Remote
Mid Level
$50/hr - $50/hr
2+ years expHealthEdge is a company focused on healthcare solutions, and they are seeking an Appeals RN to manage complex grievances and appeals requests. The role involves investigating requests, reviewing medical necessity, preparing documentation, and serving as a subject matter expert in appeals and grievances.
Enterprise SoftwareHealthcareSoftwareHealth CareProduct Design
No H1B
Responsibilities
Investigate and process complex grievances and appeals requests from members and providers
Perform reviews of inpatient, outpatient, ambulatory and ancillary services for medical necessity
Review, research, and prepare documentation related to appeals and grievances in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards
Prepare recommendations to either uphold or deny appeal and work with the Medical Director for further review
Document and logs appeal/grievance information on relevant tracking systems
Generate written correspondence to providers, members, and regulatory entities
Serve as a subject matter expert for appeals, grievances, and quality of care issues
Utilize leadership skills
Assist with or perform other relevant essential functions as required
Qualification
Required
Registered Nurse with current unrestricted Registered Nurse license
Minimum two (2) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc
Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes
Unrestricted USRN mainland license
At least 2 years experience in utilization management / review
Excellent written and verbal communication skills
Excellent customer service and interpersonal skills
Working knowledge of current industry Microsoft Office Suite PC applications
Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care, and concurrent patient management
Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings, and levels of service
Knowledge of applicable accreditation standards, and local, state, and federal regulations
Appeals and grievance experience required
Strong problem-solving skills, facilitation skills, and analytical skills
Preferred
Bachelor's degree in nursing, allied health, business, or related field
Certification in Case Management may be preferred based upon designated department assignment
One (1) year health insurance plan experience or managed care environment preferred
Medicare Advantage experience an advantage
Company
HealthEdge
HealthEdge Software offers benefits administration and care management software solutions.
1001-5000 employees
Funding
Current Stage
Late StageTotal Funding
$97.78MKey Investors
MedicaOaktree Specialty LendingPsilos Group
2025-04-08Acquired
2020-03-09Private Equity
2017-07-14Series Unknown· $34M
Leadership Team
A
Alex Saltzman
Chief of Staff to the CEO & Senior Vice President of Corporate Development
Kevin Adams
Chief Executive Officer
Recent News
Washington Technology
2026-06-03
Company data provided by crunchbase