RN Appeals Nurse (Utilization Review) in Portland, Oregon - #71932 | VanderHouwen

Description

Job Id: 71932

RN Appeals Nurse (Utilization Review)
Our client is seeking a detail-oriented and clinically strong RN Appeals Nurse (Utilization Review) to support the review and resolution of member and provider appeals. This role requires sound clinical judgment, strong written communication skills, and the ability to interpret complex medical information while ensuring compliance with regulatory and policy requirements. The ideal candidate is collaborative, analytical, and comfortable working in a fast-paced, remote environment.

This role is fully remote; applicants must reside in OR, WA, UT, or ID. Candidates must be able to work Pacific Time Zone hours and maintain flexibility to occasionally support work outside of standard business hours may be required.

RN Appeals Nurse (Utilization Review) Responsibilities

• Conduct comprehensive clinical reviews of member and provider appeals, ensuring alignment with medical necessity criteria, benefit plans, and contractual obligations.
• Apply nursing expertise and critical thinking to develop clear, well-supported appeal determinations in accordance with regulatory standards and internal policies.
• Interpret medical records, clinical documentation, and coding to support accurate and compliant decision-making.
• Collaborate with physician advisors when additional clinical guidance is needed to support appropriate outcomes.
• Ensure all appeal decisions meet applicable federal, state, and accreditation requirements, as well as industry standards of care.
• Provide clinical guidance and education to non-clinical team members regarding case details and medical concepts.
• Maintain accurate and timely documentation, including detailed written summaries and decision rationales.
• Utilize established guidelines such as MCG and coding standards (CPT, ICD, HCPCS) in the review process.

RN Appeals Nurse (Utilization Review) Qualifications

• Active, unrestricted Registered Nurse (RN) license in OR, WA, ID, or UT.
• Bachelor’s degree in Nursing (BSN) or higher.
• Minimum of 2 years of experience in health insurance, utilization management, or clinical appeals review.
• At least 3 years of direct clinical care experience (or equivalent).
• Demonstrated experience reviewing claims and working with billing and coding documentation.
• Strong knowledge of medical necessity criteria, healthcare regulations, and appeals processes.
• Proficiency in interpreting medical records, clinical data, and member benefits.
• Familiarity with CPT, ICD, HCPCS coding, and MCG (Milliman Care Guidelines).
• Ability to write clear, concise, and well-supported clinical determinations.
• Proficiency with Microsoft Office tools (Word, Excel, PowerPoint, Access).
• Excellent communication skills, with the ability to convey complex clinical information to diverse audiences.

Compensation: (DOE)

VanderHouwen Contractors Enjoy Exceptional Benefit Perks!
As an eligible contract employee with VanderHouwen, you’ll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.

Meet VanderHouwen
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VanderHouwen is an award-winning, Women & Diversity-Owned, WBENC certified professional staffing firm. Founded in 1987, VanderHouwen places experienced professionals across the nation! Our recruitment teams specialize in either Technology and IT, Engineering, Human Resources, or Accounting and Finance career markets. Partner with us to land your next exciting career!

VanderHouwen is an Equal Opportunity Employer and participates in E-Verify. VanderHouwen does not discriminate based on race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable local, state, or federal civil rights laws.

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