Remote Appeals Clinical Review LPN

Job Title: Appeals Clinical Reviewer

Job Description

The Appeals Utilization Review Nurse reviews and evaluates member and provider appeals related to medical necessity determinations, authorization decisions, and claims outcomes. This role applies clinical expertise, evidence-based guidelines, regulatory requirements, and internal policies to ensure fair, timely, and compliant appeal determinations. The nurse collaborates closely with Medical Directors, providers, claims teams, and utilization management staff to support high-quality patient care while promoting appropriate utilization of healthcare services. This position offers the opportunity to transition to a permanent role and is performed fully remotely.

Responsibilities

• Review and evaluate member and provider appeals related to medical necessity determinations, authorization decisions, and claims outcomes.
• Apply clinical expertise and evidence-based guidelines to ensure accurate, fair, and consistent appeal determinations.
• Ensure all appeal decisions comply with applicable regulatory requirements, Medicaid guidelines, and organizational policies.
• Document appeal reviews and determinations clearly, accurately, and in a timely manner within designated systems.
• Collaborate with Medical Directors to clarify complex clinical issues and support final appeal decisions.
• Work closely with providers to gather necessary clinical information and explain appeal outcomes as appropriate.
• Coordinate with claims teams to address claims-related appeals and ensure correct processing based on determinations.
• Partner with utilization management staff to align appeal decisions with utilization review processes and criteria.
• Support quality patient care by balancing member needs with appropriate utilization of healthcare services.
• Maintain confidentiality and handle sensitive member and provider information in accordance with all policies and regulations.

Essential Skills

• Active Florida Licensed Practical Nurse (FL LPN) credential.
• At least 2 years of utilization management (UM) and utilization review (UR) experience.
• At least 2 years of experience working with Medicaid populations or Medicaid programs.
• Demonstrated experience in clinical review within a managed care or similar environment.
• Strong understanding of medical necessity criteria, authorization processes, and claims outcomes.
• Ability to interpret and apply evidence-based guidelines and regulatory requirements to appeal determinations.
• Proficiency in remote work tools and electronic documentation systems.
• Excellent critical thinking, clinical judgment, and decision-making skills.
• Strong written and verbal communication skills for interaction with Medical Directors, providers, and internal teams.
• Ability to manage time effectively and complete appeal reviews within required timelines.

Additional Skills & Qualifications

• Experience in utilization management and utilization review within a managed care setting.
• Familiarity with Medicaid regulations and program requirements.
• Comfort working in a collaborative, cross-functional environment with Medical Directors, providers, claims teams, and utilization management staff.
• Attention to detail and accuracy in documentation and clinical review.
• Ability to adapt to changing guidelines, policies, and regulatory requirements.
• Interest in long-term opportunities, including potential transition to a permanent position.

Work Environment

This role is 100% remote and follows a Monday through Friday schedule, typically from 8:00 a.m. to 5:00 p.m. The position requires consistent access to a secure, professional home workspace suitable for confidential clinical and claims-related work. The nurse works virtually with Medical Directors, providers, claims teams, and utilization management staff, using electronic systems and communication tools to complete appeal reviews and documentation. The environment emphasizes compliance, accuracy, and collaboration while supporting work-life balance through standard weekday hours.

Job Type & Location

This is a Contract to Hire position based out of Saint Louis, MO.

Pay and Benefits

The pay range for this position is $28.00 - $33.00/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)

Workplace Type

This is a fully remote position.

Application Deadline

This position is anticipated to close on Jul 22, 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.