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Clinical Review Clinician - Appeals

Spectraforce Technologies
United States, North Carolina, Raleigh
500 West Peace Street (Show on map)
Jul 11, 2025
Title: Clinical Review Clinician - Appeals

Location: Remote

Duration: 6 Months with potential to extend or convert


8-5 EST or CST hours

Position Summary: Perform clinical reviews for pre-service authorization denials and retrospective claim denials to determine if members can/did receive medically necessary services.

Background & Context:



  • Shared Services Medicare Appeals department located within EBOS.
  • We are a team of 30 plus clinicians who perform clinical reviews for pre-service authorization denials as well as retrospective claim denials for both members and providers.

    Key Responsibilities:
  • Staff will work when there are members of the supervisor/leadership on.
  • Cases are assigned in round robin fashion for staff to review and work.
  • Nurses review case files, add, update or edit authorizations.
  • Work closely with the MD team to make final decisions on cases.
  • The clinical team works closely with their supervisors and senior clinicians on the team for support.
  • Team does have group chats on Teams for routine questions.
  • Team works closely together along with the coordinator team who owns end to end process on cases.

    Qualification & Experience:

    Candidate Requirements
    Education/Certification Required: Associate in nursing, Bachelor's in nursing or higher. Preferred:
    Licensure Required: RN, LPN Preferred: LVN


    • Years of experience required
    • Disqualifiers
    • Best vs. average
    • Performance indicators


    Must haves: Medicare knowledge, InterQual or Milliman Experience, Clinical reviews for Utilization Management or Appeals

    Nice to haves: Medicare Appeals Experience

    Disqualifiers: Not having a valid/active RN/LPN license

    Performance indicators: Productivity expectations vary based on platform. Prime 7 CPD, iCP 9 CPD and CenPas is 20 CPD cases per day with 95% quality on all cases

    Best vs. average: Productivity expectations are set based on platform.


    • Top 3 must-have hard skills
    • Level of experience with each
    • Stack-ranked by importance
    • Candidate Review & Selection


    1 Utilization Management or Appeals review background (1 plus year)
    2 Medicare NCD/LCD and InterQual/Milliman Software (1 plus year)
    3 Retrospective claims clinical reviews (1 plus year)


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