Clinical Appeals Nurse

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.