Nurse Reviewer – Appeals and Hearing

Gainwell Technologies

. Coordinate and perform all appeal-related duties .

Posted 11/6/2026full-timeRemote • Ohio • United StatesMid-LevelSenior💰 $69,400 - $99,200 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in clinical criteria and coding guidelines, with a strong focus on managing appeals and hearings processes. Proficient in developing clear appeal rationales and case summaries while maintaining compliance with clinical policies and regulations.

Highest-signal resume keywords

Active RN LicenseClinical ExperienceUtilization Review ExperienceMCG or InterQual ExperienceStrong Communication Skills

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical Review Criteria ApplicationAppeals Process KnowledgeClaims AuditingDocumentation ReviewCase File Preparation

Soft Skills

MentoringFeedbackTime ManagementPresentation Skills

Certifications & Qualifications

RN LicenseCoding Certification

Industry Keywords

AppealsHearingsClinical PoliciesCoding GuidelinesProvider Appeals

About the role

Key responsibilities & impact

Coordinate and perform all appeal-related duties
Analyze and respond appropriately to provider appeals
Review documentation to ensure all aspects of appeals are properly and accurately addressed
Review provider appeals and redeterminations using approved clinical and coding guidelines
Document appeal determinations clearly and concisely
Prepare case files and case summaries for hearings
Actively participate in virtual and on-site hearings with the Medical Director
Assist management with training new reviewers through daily monitoring, mentoring, feedback, and education
Maintain current knowledge of clinical criteria and/or coding guidelines
Attend training and scheduled meetings to enhance knowledge of clinical policies, procedures, rules, and regulations
Cross-train to review multiple claim types and support client needs

Requirements

What you’ll need

Active, unrestricted RN license in the United States
If applicable, an active multistate RN license under the Nurse Licensure Compact (NLC)
5+ years of clinical experience or medical record coding experience
3+ years of utilization review or claims auditing experience
Working knowledge of the appeals and hearings process
Experience applying clinical review criteria
MCG or InterQual experience preferred
Strong written and verbal communication skills
Ability to develop clear, fact-based appeal rationales
Ability to present case summaries and decisions
Ability to manage multiple priorities in a fast-paced environment
Ability to attend training and scheduled meetings
Ability to successfully complete required CEUs to maintain RN license and/or coding certification

Benefits

Comp & perks

Flexible working hours
Work-life balance
Career development
Flexible vacation policy
401(k) employer match
Comprehensive health benefits
Educational assistance
Leadership and technical development academies
Up to 25% travel for onsite hearing testimony