RN Clinical Appeals & Utilization Review - Remote

BCforward is currently seeking a highly motivated RN Clinical Appeals & Utilization Review for an opportunity in Columbus , OH

Position: RN Clinical Appeals & Utilization Review

Location: Remote – Ohio; Columbus area preferred

Duration: 6 months, with possibility of extension or conversion

Work Type: Remote

Shift: Monday–Friday, 8:00 AM–5:00 PM

Job Information:

The ideal candidate will have experience in Utilization Review/Utilization Management, appeals or authorization review, strong clinical documentation skills, and the ability to independently manage a high volume of appeal cases while meeting compliance and turnaround-time requirements.

Key Responsibilities

• Perform clinical reviews of medical necessity appeals involving denied authorizations and prior authorization decisions.
• Review medical records, clinical information, medical codes, authorization documentation, and applicable criteria to determine appropriate appeal outcomes.
• Analyze denied authorization/prior authorization cases and prepare complete case summaries for Medical Director review.
• Review medical code data and clinical records to determine whether a denial is supported by applicable criteria and guidelines.
• Make appeal determinations, document outcomes, send appropriate determination letters, and close cases in the applicable system.
• Prepare clear and accurate written appeal and authorization outcome letters for members and providers.
• Maintain complete and accurate appeal files and documentation.
• Utilize multiple claims and appeals systems to research information and complete clinical reviews.
• Apply medical necessity criteria, health plan policies, and applicable regulatory and quality standards, including NCQA requirements.
• Manage approximately 10–15 appeals per day after training while ensuring work queues remain within required compliance turnaround times.
• Communicate effectively with team members and leadership through email and Microsoft Teams.
• Adapt to changing priorities and assist with additional team needs as required.
• Support related health plan activities, including claims research, data entry, tracking, and documentation when needed.
• Handle large volumes of documents and clinical information while maintaining accuracy and confidentiality.

Required Qualifications

• Active LPN license required.
• RN license preferred but not required.
• Minimum 2 years of Utilization Review/Utilization Management experience.
• Experience reviewing medical necessity appeals, denied authorizations, or prior authorization cases.
• Experience reviewing medical records and clinical data to support appeal determinations.
• Knowledge of medical coding and ability to interpret medical code information.
• Strong written, verbal, analytical, and problem-solving skills.
• Comfortable working with multiple clinical, claims, and appeals systems.
• Proficiency with Microsoft Office programs.
• Ability to manage a high-volume workload while meeting turnaround-time requirements.

Preferred Qualifications

• RN license.
• Direct patient care experience.
• Experience writing appeal or authorization outcome letters.
• Experience with TruCare and/or Amisys.
• Experience with grievance and appeals processes.
• Experience working in a health plan or managed care environment.
• Stable work history and demonstrated ability to work independently.

Benefits:

BCforward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.