Nurse, Clinical Appeals

We are seeking an experienced Clinical Appeals Nurse to support the appeal and grievance processes by analyzing and responding to adverse coverage decisions. This role involves clinical judgment, regulatory knowledge, and strong communication skills to ensure all responses meet State and Federal compliance requirements. The role is fully remote and requires an active Registered Nurse (RN) license.

Appeals & Reconsideration Processing (35%): Investigate and interpret written appeals from members, providers, attorneys, and other stakeholders Craft original response letters based on corporate policy and regulations Ensure compliance with all applicable State and Federal mandates Case Preparation for Clinical Review (35%): Compile and organize relevant clinical, contractual, and policy documentation Formulate case summaries and recommendations Communicate final decisions post-physician review, including external appeal rights Clinical Assessment & Compliance (25%): Evaluate medical and behavioral health appeal requests using clinical expertise Interpret regulatory/accreditation guidelines to ensure proper case handling Collaborate with Independent Review Organizations and panel physicians Address complaints from CMS and other regulatory bodies Medical Knowledge Maintenance (5%): Maintain up-to-date knowledge of medical, psychiatric, surgical, and diagnostic terminology Understand complications and comorbidities related to medical and behavioral health conditions