Medix™
Appeals Nurse - 253261
Company Description
Medix provides workforce solutions to clients and creates opportunity for talent in the Healthcare, Life Sciences, Engineering and Technology fields. Through our core purpose of positively impacting lives, we have earned our reputation as an industry leader by providing unsurpassed customer service and top quality professionals to our clients.
Job Description
Utilization Management RN – Inpatient Appeals (Remote | Contract) Equipment - need to have their own equipment - Laptop (windows OS) & extra monitor Contract: until Nov 2026 We’re partnering with a growing Medicare Advantage health plan seeking experienced Utilization Management RNs to support inpatient appeals during a period of rapid expansion and increased case volume. This is a high-impact, fast-paced role ideal for nurses who can step in quickly, think critically, and produce strong, defensible clinical determinations with minimal ramp time.
Requirements
Active, unrestricted RN license 3+ years of Utilization Management experience Direct inpatient appeals experience (payer/health plan required) Strong knowledge of InterQual and/or MCG criteria Proven ability to write clinical justifications for appeals Ability to work independently in a high-volume environment Nice to Have: Medicare Advantage experience Exposure to appeals & grievances processes Experience with complex/escalated cases Background in both hospital and payer settings Key Strengths for Success Strong clinical judgment & analytical thinking Clear, concise documentation skills High attention to detail Confident, independent decision-making Ability to balance quality with productivity Comfortable navigating pushback and escalations Process-driven and compliance-focused mindset What Success Looks Like: Independently managing inpatient appeals with minimal oversight Producing clear, defensible determinations Maintaining strong productivity and accuracy Helping reduce appeals backlog quickly
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Responsibilities
Review inpatient cases at the appeals level (post-denial) Evaluate medical necessity, level of care, and length of stay Apply InterQual and/or MCG (Milliman) criteria Develop clear, defensible clinical rationales (uphold or overturn) Ensure compliance with Medicare Advantage and regulatory guidelines Collaborate on complex or escalated cases Maintain accurate and timely documentation Manage a consistent caseload while meeting productivity expectations
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