Appeals Processor - RN

Posted yesterday

ghost rxDenver (CO)

Registered Nurses Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds

SENIORITY

Senior

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About the role

Appeals Processor III - RNWe are seeking a highly skilled Appeals Processor III (APP III) to join our dedicated team in a remote capacity. The Appeals Processor III (APP III) is responsible for reviewing, analyzing, and processing healthcare appeals related to Medicaid or Medicare coverage decisions. This role ensures all cases are handled in compliance with federal/state regulations, CMS guidelines, and contract requirements. Qualification and Requirements

Requirements: Associate's Degree (Bachelor's preferred)2+ years in:

Healthcare appeals
Medical claims / utilization review
Insurance or Medicaid/Medicare processing
Strong knowledge of:
CMS guidelines
Medicaid/Medicare (especially Part C)
Experience reviewing medical documentation (clinical roles may require RN)

Responsibilities

Duties:

Review incoming appeals, medical records, and supporting documentation
Analyze cases using state/federal regulations and CMS guidelines
Determine if additional documentation is required and request it when needed
Process appeals from start to finish, including final determinations
Decision Support & Documentation
Prepare case summaries and ensure files are complete for review
Draft or support writing determination/decision letters
Ensure all documentation meets quality and compliance standards

GhostRX, Inc. is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, sexual orientation, and gender identity), national origin, age, disability, genetic information, protected veteran status, or any other characteristic protected by applicable law. If you are unable to apply due to a disability, you may request a reasonable accommodation by contacting hr@ghostrx.com or dialing 711 (TTY). This contractor and subcontractor abides by the requirements of 41 CFR 60‐1.4(a), 41 CFR 60‐300.5(a), and 41 CFR 60‐741.5(a). These regulations prohibit discrimination against qualified individuals on the basis of protected veteran status or disability and require affirmative action by covered prime contractors and subcontractors to employ and advance in employment qualified protected veterans and individuals with disabilities.

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