Job Description

We are seeking a highly skilled and detail‑oriented Appeals PHRN Specialist to support our expanding Medicare line of business. The ideal candidate will have a strong background in Utilization Management (UM), appeals processing, and case validation, with hands‑on experience in Medicare UM or Appeals. This role will be critical in ensuring high‑quality clinical review, thorough case investigation, and timely resolution of appeal cases in accordance with CMS guidelines.

Job Title

Clinical BP_2026

Appeals Review & Case Handling

• Review, evaluate, and process appeal requests for Medicare members in compliance with CMS regulations and organizational protocols.

Collaboration

• Collaborate with onshore payer nurses and Independent Review Organizations (IROs) to collect and verify necessary documentation for appeal resolution.
• Escalate complex cases as needed, providing detailed su...