New

Appeals Nurse

Spectraforce Technologies

United States, Iowa, Des Moines

Jul 29, 2026

Title: Appeals Nurse

Duration: 8 Months - Possible extension/Conversion

Location: Remote - Iowa

Note: Would only be required to work onsite if hired after the contract. Address is 1080 Jordan Creek Pkwy, West Des Moines

Job Summary

Position Purpose: Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met

Key Responsibilities:

Review and process Iowa Medicaid Member Appeals
Member appeal requests are received and assigned by the team lead, the appeals nurse is responsible for working the appeal start to finish.
Outreach attempts are made to member/provider.
A clinical review is completed and case sent to specialty review/MD.
Appeals nurse will write determination letters and close the case.
30 calendar days to complete standard cases and 3 business days to acknowledge receipt of the case.
This team handles all Iowa Medicaid appeals except behavioral health
Review clinical data to determine claim payment based on company policies and
National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review
Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions
Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution
Gather and prepare case information for Administrative Law Hearings
Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database
Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements.

Candidate Requirements
Education/Certification	Required: Associates	Preferred:
Licensure	Required: LPN	Preferred: RN
Years of experience required: at least 2 years nursing experience, UM experience helpful Disqualifiers: none Additional qualities to look for: The ideal candidate will thrive in a fast?paced environment with frequently changing workloads. This role requires strong prioritization, organization, and adaptability.
Top 3 must-have hard skills stack-ranked by importance	1	Customer service
2	Time management
3	Computer skills/ability to learn new systems