Clinical Appeals Nurse

About This Role

Join a high-performing Appeals Department, leveraging clinical judgment to make timely, compliant, and clinically sound appeal determinations for Medicare and Commercial lines of business. This role involves close collaboration with physicians, non-clinical partners, and leadership in a fast-paced environment.

Responsibilities

• Perform clinical review of complex and non-routine appeals and grievances
• Apply clinical coverage criteria, Corporate Medical Policy (CMP), and contract provisions to appeal determinations
• Support Level 3 appeals and physician committee presentations
• Review and analyze medical records and external documentation
• Coordinate with providers, attorneys, pharmaceutical companies, and external vendors
• Prepare professional, organized clinical summaries and written appeal determinations
• Identify trends, compliance gaps, and high-risk exposure areas
• Initiate claim adjustments when appropriate
• Respond to member and provider inquiries professionally
• Ensure compliance with NCQA, federal, state, and regulatory requirements
• Support utilization management and preservice appeal workflows

Requirements

• Active Registered Nurse (RN) license or minimum 3 years of clinical experience (RN)
• Experience with Medicare / Medicare Advantage
• Strong understanding of clinical coverage criteria and medical necessity review
• Experience reviewing medical records and clinical documentation

Qualifications

• Minimum 3 years of clinical experience as a Registered Nurse (RN)

Nice to Have

• Clinical appeals and grievance review experience
• Utilization Management (UM) exposure (any level)
• Experience with preservice appeals
• Familiarity with Care Radius platform
• Strong independent clinical judgment and ability to work in ambiguous scenarios
• High level of organization and time management

Skills

* Required skills