Grievance and Appeals Clinical Review Nurse (RN/LVN)

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values.

The Clinical Review Nurse evaluates medical records and clinical documentation to support the resolution of claims, member grievances, appeals, and quality-of-care concerns. Using clinical judgment and appropriate application of CMS regulations, Medicare Advantage requirements, and evidence-based guidelines, this role conducts retrospective clinical reviews and prepares complete, accurate, and audit-ready case files for Medical Director review and determination. Claims are defined as: Initial payment determinations for covered Part C and Part D services Post-service claims requiring clinical review to support payment accuracy and benefit application Claims requiring medical necessity, level-of-care, or appropriateness-of-care assessment Claims involving retrospective review of medical records or clinical documentation Provider payment disputes requiring clinical validation (non-appeal) High-dollar, complex, or high-risk claims requiring clinical review prior to final determination Claims requiring coordination with Medical Management, Claims Operations, or Medical Director review Appeals and Grievances are defined as: Organization Determinations / Coverage Requests (pre-service) Part C reconsiderations (standard & expedited) Part D redeterminations/coverage determinations (if applicable) Payment disputes/claim appeals (if in scope) Quality of Care grievances Appeal withdrawals/dismissals & validity checks (authorized rep, timeliness, etc.) The Clinical Review Nurse applies clinical acumen to assess medical necessity, appropriateness of care, and quality of services rendered; documents findings in designated medical management systems; and collaborates with non-clinical staff to ensure timely, compliant, and defensible case resolution.

Provide clinical review support for claims, claim appeals, grievances, provider disputes, and quality of care grievances, including retrospective review of medical records and claims. Conduct clinical reviews to assess medical necessity, appropriateness of care, and quality of services rendered, using clinical judgment and applicable CMS guidelines, Medicare manuals, and plan policies. Prepare clear, concise clinical summaries and recommendations for Medical Director review, including identification of key clinical facts, regulatory considerations, and applicable coverage or clinical criteria. Support the preparation and review of Quality of Care (QOC) grievance cases for Medical Director evaluation, including identification of potential care issues, documentation gaps, and quality concerns. Apply nationally recognized clinical decision support tools and guidelines (e.g., InterQual, MCG, NCDs/LCDs, specialty society guidance) as applicable to clinical reviews. Review and interpret medical coding and billing information (CPT, HCPCS, ICD-10-CM/PCS, DRG, Revenue Codes) to support accurate clinical assessment. dentify missing or insufficient clinical documentation and coordinate with providers or internal departments to obtain additional information. Enter, maintain, and validate clinical documentation and review outcomes in medical management and case tracking systems. Ensure cases are prepared and routed within required CMS and contractual turnaround timeframes; maintain awareness of standard vs expedited timeframes and tolling requirements when records are pending. Escalates risks to prevent late determinations; escalates cases at risk of noncompliance same day when barriers arise (missing records, invalid auth rep, misrouted cases). Respond accurately and timely to Medical Directors, Claims, Appeals and Grievances staff, and other internal stakeholders regarding clinical findings. Assist with CTM-related clinical case review and provide clinical input to support compliant complaint resolution. Participate in audit readiness activities, including case file review, universe validation, and response to regulatory or oversight entity requests. Audit clinical reviews to ensure compliance with Claims, Appeals and Grievances, and medical management policies and procedures. Provide clinical guidance and act as a clinical resource to non-clinical staff. Participate in special projects related to Claims, Appeals and Grievances operations, quality improvement, or regulatory compliance. Participate in required training and assist with onboarding and education of new or existing staff as needed. Ensures all case documentation supports CMS audit and legal defensibility, including record inventory, clinical criteria citations, decision rationale, and accurate system time stamps. Differentiates and prioritizes standard vs expedited requests and applies tolling/extension rules as applicable per policy. Maintains HIPAA compliance and secure handling of PHI in all systems and remote work environments. Other duties as assigned.