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.

About BCforward:

Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward’s 6,000 consultants support more than 225 clients globally.

BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.