Appeals Nurse

This role focuses on reviewing clinical data to determine appropriate claim payment decisions in alignment with organizational policies and National Committee for Quality Assurance (NCQA) guidelines. The nurse in this position evaluates appeals, prepares cases for medical review, and ensures timely and accurate resolution of appeals while supporting regulatory and contractual compliance.

• Review clinical data to determine claim payment decisions based on company policies and NCQA guidelines.
• Evaluate denied claims and determine whether to overturn denials, uphold denials, or submit cases to the Medical Director for further review.
• Prepare detailed case reviews for the Medical Director when clinical criteria are not met based on the additional information received.
• Generate clear and compliant appeal resolution communications to members and providers in accordance with company policies and NCQA guidelines.
• Create system authorization events for overturned denial decisions to ensure accurate documentation and processing.
• Request additional clinical information from providers, as appropriate, to facilitate timely and complete appeals resolution.
• Gather and prepare comprehensive case information for Administrative Law Hearings.
• Maintain the appeals process within prescribed NCQA timeframes and ensure accurate tracking in the appeals turnaround database.
• Assist the Medical Director in revising, updating, and creating new policies to satisfy NCQA requirements and contractual obligations.

• Licensed Practical Nurse (LPN) with at least 3 years of clinical nursing experience, or Registered Nurse (RN) with at least 2 years of clinical nursing experience.
• Active RN or LPN license in good standing.
• For designated positions, an active New York State RN license is required.
• Proficiency with Microsoft Office applications, including word processing, spreadsheets, and email.
• Ability to interpret and apply organizational policies and NCQA guidelines to clinical and claims information.
• Strong clinical judgment and critical thinking skills to evaluate appeals and determine appropriate outcomes.
• Excellent written communication skills for preparing case reviews and appeal resolution letters.
• Strong organizational skills to manage multiple appeals and maintain required turnaround times.

• Experience with utilization review or appeals review is preferred.
• Knowledge of InterQual criteria is preferred.
• Familiarity with regulatory and accreditation standards related to NCQA is beneficial.
• Experience preparing materials for Administrative Law Hearings is an advantage.
• Ability to collaborate effectively with Medical Directors and other clinical and non-clinical stakeholders.

The role operates in a structured, compliance-driven environment focused on clinical review, appeals processing, and adherence to NCQA and contractual requirements. Work is primarily computer-based, using Microsoft Office applications and internal authorization and appeals tracking systems to document decisions, create authorization events, and maintain appeals turnaround databases. The position requires careful attention to detail, consistent documentation, and timely completion of tasks within defined timeframes. Collaboration with Medical Directors, providers, and internal teams is a regular part of the workday, typically within standard business hours.

This is a Contract position based out of West Des Moines, IA.

The pay range for this position is $33.00 - $38.00/hr.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: • Medical, dental & vision • Critical Illness, Accident, and Hospital • 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available • Life Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term disability • Health Spending Account (HSA) • Transportation benefits • Employee Assistance Program • Time Off/Leave (PTO, Vacation or Sick Leave)

This is a fully remote position.

This position is anticipated to close on Aug 7, 2026.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 20,000 consultants and 5,000 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. We are proud to be an Engineering News-Record (ENR) Top 500 Design Firm for our engineering design services and a ClearlyRated Best of Staffing® winner for both client and talent service.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.

San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the city and county of San Francisco, we will consider for employment qualified applicants with arrest and conviction records.

Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess applications and qualifications, but final decisions are made by our hiring team. By applying, you acknowledge and agree that your application may be reviewed using AI tools.

Salary : $33 - $38