Appeals Nurse

Compunnel Inc. is where AI-native solutions meet human ingenuity, helping enterprises reimagine talent, technology, and growth. A world where your people and your platforms don’t just coexist — they co-elevate. At Compunnel, we build bridges between intelligent systems and human potential, forging paths to transformation in real time. For over 30 years, we’ve been the quiet force behind digital revolutions. We speak two languages fluently: empathy and algorithm. Our AI-powered infrastructure weaves into human workflows (not over them), enabling clients to scale with agility, adapt with foresight, and compete with confidence. From coast to coast in the U.S. (30+ delivery centers) and across global innovation hubs in Canada, India, and the UK, we serve 200+ clients — including 23% of the Fortune 500. Whether you’re a global enterprise or a public sector agency, you lean on us for recruitment (IT, non-IT, public sector) and future-forward digital capabilities.

Serve as a clinical resource within the Medical Management team, responsible for reviewing medical documentation and determining the medical necessity of services. This role ensures compliance with InterQual criteria and contract requirements, and facilitates appeal reviews by either approving cases or escalating to a Medical Director.

Review all submitted materials including EMRs and supporting documentation to assess completeness and compliance. Apply InterQual criteria and contract guidelines to determine medical necessity. Make initial determinations on cases; approve or escalate to MD for further review. Prepare and submit appeal letters in accordance with NCQA and state regulations. Coordinate with internal departments and external review organizations for fair hearings and appeals. Maintain accurate logs and documentation for all appeal decisions. Stay current with NCQA, CMS, and state regulatory updates. Support continuity of care and ensure timely resolution of member and provider inquiries.