Appeals Clinician I

This is a fully remote position, open to applicants in Idaho, +3 more states.

📋 Description

• Fulfill the clinical aspects of all types of appeals to address member and/or provider appeals.

• Utilize nursing expertise and clinical judgment to guarantee that written appeal resolutions align with medical policies, medical necessity guidelines, reimbursement policies, federal regulations, company policies, industry standards, and accepted care practices.

• Perform clinical appeal reviews in compliance with member benefits and provider and hospital agreements.

• Collaborate with physician advisers to confirm clinically suitable determinations when necessary.

• Guide and inform non-clinical appeals personnel on clinical matters.

⛳️ Requirements

• Bachelor’s Degree in Nursing along with 3 years of experience in a clinical environment, health insurance, coding/claims review, case management, or an equivalent combination of education and experience.

• Active licensure or certification in a state or territory of the United States in a health or human services discipline permitting independent assessments within the scope of practice.

• Minimum of 3 years (or full-time equivalent) of direct clinical care experience.

• Current unrestricted Registered Nurse (RN) license in Oregon, Washington, Idaho, or Utah.

• Proven skills in claim review and familiarity with billing and claims forms.

• Understanding of medical and surgical procedures and healthcare practices.

• Proficiency in applying clinical expertise to ensure adherence to medical policies.

• Awareness of appeal regulations set by accrediting organizations, state and federal authorities, and employer groups.

• Capability to read and interpret medical records, patient data, and member benefits.

• Skill in effectively communicating complex subjects to both clinical and non-clinical staff.

• Proficient in Microsoft Word, Excel, PowerPoint, and Access.

• Competence in preparing and delivering clear, concise written narratives and decisions.

• Familiarity with CPT, ICD-9, HCPCS coding, and MCG (Milliman Care Guidelines).

• Experience with AI tools and technologies is highly desirable.

• Reliable wired internet connection required; minimum upload speed of 5 Mb and download speed of 10 Mb; satellite or cellular connections are not accepted.

• Personal mobile device required for Multi-Factor Authentication.

• Background check is mandatory.

🏝️ Benefits

• Competitive salary.

• Bonus opportunities.

• Market-leading 401(k) with a substantial company match.

• Potential discretionary 401(k) contribution based on company performance with no vesting period.

• Comprehensive medical, dental, and vision coverage for employees and eligible family members, including mental health benefits.

• Annual employer contribution to a health savings account.

• Generous paid time off.

• 10 company-paid holidays.

• Up to 12 weeks of paid parental leave, subject to eligibility.

• Award-winning wellness programs that incentivize participation.

• Employee Assistance Fund.

• Commute and parking benefits.

• Work-from-home options available for most roles.

• Employee resource groups.

• Cambia-supported outreach initiatives.

• Opportunities for career growth and professional development.