Clinical Appeals Nurse

Fully remote, long-term contract role focused on clinical review, appeal resolution, regulatory compliance, and member/provider support within a complex health insurance environment.

Responsibilities

• Evaluate complex appeal and grievance cases by interpreting clinical guidelines, benefit language, regulatory requirements, and coverage policies to support fair and accurate determinations.
• Serve as a clinical resource for non-clinical team members, offering guidance throughout the appeal review process and ensuring adherence to established standards.
• Gather and assess supporting medical records and documentation from healthcare providers, legal representatives, outside organizations, and other relevant sources.
• Prepare case summaries and recommendations for physician reviewers, leadership teams, and review committees, while facilitating necessary claim corrections and adjustments.
• Respond to member and provider inquiries, identify process improvement opportunities, and help develop corrective actions related to benefits interpretation, policy application, or claims processing issues.

Requirements

• Active Registered Nurse (RN) license in the State of North Carolina with a minimum of three years of clinical experience; OR active LPN, Physical Therapist (PT), or Occupational Therapist (OT) license in North Carolina with at least five years of clinical experience.
• Strong understanding of healthcare regulations, medical necessity review standards, utilization management principles, and appeals processes.
• Experience reviewing medical documentation and applying clinical judgment in support of coverage or reimbursement determinations.
• Excellent written and verbal communication skills with the ability to present clinical findings to both technical and non-technical audiences.
• Proven ability to manage multiple priorities, maintain accuracy in a deadline-driven environment, and work independently in a remote setting.

Pay

Salary Range: $70,000 - $80,000 annually

Benefits

• Medical, Dental, Vision
• Sick leave if required by law
• 401K