Appeals & Utilization Management Nurse

Why Choose Epitec? Founded in 1978 and headquartered in Southfield, Mich., with regional hubs in Chicago, Central Illinois, and Dallas, Epitec is dedicated to making staffing personal. Our customers include Fortune 500 companies across the United States, providing you access to high demand career opportunities. What Makes Epitec Different? Our flexible workforce model is designed with you in mind. Whether you're looking for contract-to-hire, direct hire, or other employment options, we tailor our services to fit your career goals. We are consistently ranked as a top supplier to our customers, ensuring you have access to premier job placements. How We Support You Our recruiting team focuses on understanding your unique skills and aspirations and we expertly match those to our customer job opportunities. We bring together diverse teams to solve complex problems, ensuring you are placed in roles where you can thrive. By leveraging innovative strategies and technology, we adapt to your evolving needs, providing exceptional support every step of the way. Our Commitment to Your Success Epitec’s dedication to excellence has earned us national recognition as a “Best and Brightest Company to Work For” over 20 consecutive years and MMSDC's Minority Supplier of the Year on four occasions. We are committed to your professional growth and success, making sure you have the resources and opportunities to excel in your career.

Job Title: Appeals & Utilization Management Nurse Location: United States Job Type: W2 Contract Expected Hours Per Week: 40 hours per week Schedule: Monday–Friday, 9:00 AM to 5:00 PM, Remote Pay Range: $38 per hour Position Description: We are seeking an experienced Appeals / Utilization Management Nurse to support the resolution of member and provider appeals in a managed care environment. This role partners closely with Utilization Management, Case Management, and Customer Service teams to ensure appeals are processed in compliance with regulatory, accreditation, and organizational standards while delivering a high level of customer service.

Collaborate with Utilization Management (UM), Case Management (CM), and Customer Service teams to ensure appeals processes meet established guidelines. Facilitate end-to-end resolution of member and provider appeals in compliance with state and federal regulations. Manage individual appeal inventory using established workflows while meeting required turnaround times. Ensure compliance with NCQA, URAC, DOI, and other regulatory and accreditation standards. Participate in NCQA and URAC audits, DOI audits, correspondence revisions, and departmental process improvement initiatives. Provide data and reporting required for audits, regulatory reviews, and internal stakeholders. Facilitate member or member-designee access to appeal files in accordance with federal guidelines. Work directly with members and providers to resolve appeals while maintaining superior customer service standards. Serve on departmental workgroups and support cross-functional teams. Maintain strong working relationships across organizational lines to achieve operational goals. Communicate professionally with leadership, peers, members, and providers. Maintain strict compliance with HIPAA, Corporate Integrity, Diversity Principles, and all applicable corporate policies. Preserve confidentiality of protected health information and company business. Communicate workflow updates, trends, and development needs to management; complete special projects as assigned.