Clinical Appeals Nurse - 171208

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. Qualifications: 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. Compensation: Salary Range: $70,000 - $80,000 annually Comprehensive Benefits: Medical, Dental, Vision, sick leave if required by law, and 401K Application Details Posting Date: August 7, 2026 Apply By Date: August 31, 2026 Work Arrangement: Fully Remote Employment Type: Long-Term Contract