Remote HEDIS RN Appeals Specialist

Imagine360 is seeking an Appeals Review Specialist to join our remote team. The role focuses on reviewing claims for errors, addressing provider inquiries, and generating denial explanations while maintaining strict confidentiality. Responsibilities include researching questions, training staff, and contributing to quality improvement efforts to protect plan...

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to lead clinical case development and resolution while ensuring compliance with federal and state regulations. You will manage your own caseload, prepare cases for Medical Director Review and external appeals, and handle DOH complaints as needed. The role supports both remote and on-site work...

Humana is seeking a Grievances & Appeals Representative 3 to manage members and provider Part B denials by reviewing clinical documentation and delivering final determinations with clinical partners. This is a remote, full-time role requiring independent judgment and strong coordination. The position demands 1+ year in customer service and G&A, healthcare...

A leading healthcare organization is seeking a Supervisor of Quality Operations to coordinate HEDIS and STARs data processes. This role requires a Registered Nurse with significant experience in data analysis and quality assurance. The position offers the flexibility to work remotely from anywhere in the U.S., supporting health equity through quality...

UnitedHealth Group is seeking a Senior Clinical Administrative RN to support Texas remote reviews of appeals and fair hearings. The role emphasizes clinical review, chart audits, and collaboration with cross-functional teams to ensure accurate determinations and compliance. In Texas, you may telecommute while handling state/federal regulatory review, audits,...

Spectraforce Technologies, Inc. is seeking a Quality Improvement Specialist (HEDIS) for a remote, 6-month assignment. You will support development and maintenance of quality improvement projects and assist in the clinical aspects of medical record review for health plans. Responsibilities include training providers and staff in QI methodologies, performing...

Mosaic Life Care is seeking a Clinical Documentation Integrity Specialist (RN) to perform basic-to-intermediate workflow reviews of clinical documentation for hospital admissions. You will abstract data, assign ICD-10-CM/PCS codes, and determine DRG baselines, collaborating with physicians as needed. The role requires RN licensure (state or compact), 3 years...

SCAN, a nonprofit health organization serving older adults, seeks an HEDIS Nurse for remote data abstraction and outreach. You will review records, coordinate with members and providers, and support quality initiatives per NCQA guidelines. Ideal candidates are RN or LVN with 2–3 years of related experience, an associate or technical degree, and the ability...

Allied Benefit Systems, LLC is seeking an Appeals Specialist to manage the organization and completion of claim appeals in a fully remote role. The position requires 3+ years of experience with medical/dental/vision claims, and proficiency in Excel and Word; Microsoft Access is a plus. You will review appeals, prepare response letters, and maintain precise...