Clinical Appeals Reviewer (Licensed Healthcare Professional) in United States at Jobgether

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Clinical Appeals Reviewer (Licensed Healthcare Professional) based in the United States.

This is a fully remote clinical decision-making role focused on conducting independent, evidence-based reviews of medical appeals for federal healthcare programs. You will evaluate complex case files, assess medical necessity, and ensure determinations align with applicable regulations, policies, and clinical guidelines. The role requires strong clinical judgment, attention to detail, and the ability to translate medical evidence into clear, defensible written decisions. You will serve as an impartial reviewer, helping ensure fairness, accuracy, and compliance in healthcare determinations that directly impact beneficiaries and providers. The environment is structured, mission-driven, and highly detail-oriented, with opportunities to contribute to quality improvement and mentor others. This position is best suited for experienced licensed clinicians who are confident in independent decision-making and regulatory interpretation.

In this role, you will be responsible for reviewing clinical appeal cases and producing well-supported, impartial determinations based on medical evidence and regulatory requirements. You will ensure that all appeal issues are thoroughly addressed and that decisions are clearly documented in compliance with federal guidelines.

• Review medical records and case files to determine medical necessity and appeal outcomes.
• Prepare clear, concise, and well-reasoned reconsideration decision letters supported by clinical evidence.
• Conduct independent clinical reviews aligned with applicable federal laws, Medicare regulations, and policy guidelines.
• Ensure all appeal issues raised by patients, providers, or representatives are fully evaluated and addressed.
• Research medical literature, coverage policies, and regulatory guidance to support determinations.
• Participate in case discussions, quality reviews, and cross-functional meetings as needed.
• Serve as a subject matter resource and support mentoring or training of other staff when required.

The ideal candidate is a licensed healthcare professional with strong clinical expertise, regulatory knowledge, and experience in medical review or appeals processes. You should be confident in making independent determinations and documenting complex clinical reasoning with precision.

• Active license as an RN, PT, OT, RT, or other qualified healthcare professional.
• Minimum 3 years of experience in medical review, Medicare appeals, utilization review, or related clinical decision-making roles.
• Strong knowledge of Medicare regulations, coverage rules, and healthcare compliance frameworks.
• Experience writing medical necessity determinations or clinical review decisions.
• Ability to interpret clinical data, policies, and legal/regulatory documentation.
• Strong analytical, reasoning, and problem-solving skills with high attention to detail.
• Excellent written and verbal communication skills, including professional medical documentation.
• Ability to manage competing priorities and meet strict deadlines in a structured environment.
• Must meet federal contract requirements, including U.S. residency history and eligibility for public trust clearance.

• Fully remote position anywhere in the United States
• Competitive compensation aligned with clinical experience and specialization
• Opportunity to work on federally regulated healthcare programs
• Structured training and onboarding for appeals processes and systems
• Exposure to complex clinical review work and federal healthcare policy
• Collaborative environment with opportunities for mentorship and professional growth
• Stable, mission-driven work supporting healthcare fairness and compliance
• Potential for occasional flexible scheduling depending on case workload