Clinical Appeals Nurse

About the role

Piper Companies is seeking a Clinical Appeals Nurse to join a leading health insurance organization for a contract remote opportunity located in North Carolina. The Clinical Appeals Nurse will serve as a clinical resource within the appeals team, reviewing complex cases, ensuring regulatory compliance, and supporting accurate benefit determinations. The Clinical Appeals Nurse will work closely with internal stakeholders, providers, and members to facilitate timely appeal resolutions across multiple lines of business.

Responsibilities

• Evaluate complex member and provider appeals by reviewing clinical records, policy guidelines, benefit plans, and regulatory requirements to support appeal determinations.
• Provide clinical guidance and consultation to non-clinical appeals staff throughout the review and resolution process.
• Obtain and assess medical documentation from providers, legal representatives, pharmaceutical organizations, and other external partners as needed.
• Present case findings and recommendations to physicians, leadership teams, and review committees while coordinating necessary claim adjustments.
• Identify appeal trends, compliance concerns, and operational issues, recommending process improvements and educational initiatives to reduce future risk.

Qualifications

• Active Registered Nurse (RN) license in the State of North Carolina with at least 3 years of clinical experience.
• OR active North Carolina licensure as an LPN, Physical Therapist (PT), or Occupational Therapist (OT) with 5+ years of clinical experience.
• Strong understanding of healthcare appeals, grievance processes, utilization management, and medical necessity reviews.
• Experience interpreting clinical documentation, insurance benefits, healthcare regulations, and medical policies.
• Excellent analytical, organizational, communication, and problem-solving skills with the ability to manage multiple priorities.

Pay

• Hourly Rate: $25-$35 per hour

Benefits

• Medical, Dental, Vision, sick leave if required by law, and 401K.