Position Summary:

• The Clinical Appeals Specialist is responsible for the investigation, analysis, and resolution of member and provider appeals and reconsideration requests related to adverse coverage decisions.
• This role requires strong clinical judgment, knowledge of healthcare regulations, and the ability to synthesize complex medical and regulatory information to support fair and compliant outcomes.
• The specialist acts as a liaison between internal stakeholders, members, providers, and reviewing physicians, ensuring all appeal processes adhere to State and Federal requirements for Commercial and Government Program lines of business.

Pay Range: $40 - $46 an hr. 

Key Responsibilities:

• Appeals Review & Analysis (35%)
  Investigate and interpret appeals from members, providers, attorneys, and internal departments. Prepare complex, original responses that uphold corporate policies while complying with Federal and State regulatory standards.

• Case Preparation & Recommendation (35%)
  Compile comprehensive clinical, contractual, policy, and claims documentation. Organize cases for physician review and formulate disposition recommendations. Communicate outcomes to members and providers with clarity and in accordance with regulatory appeal rights.

• Clinical Evaluation (25%)
  Apply nursing expertise and clinical knowledge to assess the appropriateness of adverse determinations. Utilize medical policies and current clinical guidelines for both physical and behavioral health conditions. Collaborate with Independent Review Organizations (IROs) and panel physicians to validate decisions.

• Regulatory Compliance & Medical Expertise (5%)
  Maintain up-to-date knowledge of medical, surgical, behavioral health, and substance abuse treatment practices. Respond to inquiries from regulatory bodies, including CMS, ensuring timely and compliant communication.

Required Qualifications:

• Education:

  • High School Diploma or GED (Required)

  • Associate Degree in Nursing (Minimum)

• Licensure:

  • Registered Nurse (RN) – Active and unrestricted license in state of employment or Compact State (Required)

• Experience:

  • Minimum 2 years of clinical nursing experience in medical-surgical or equivalent setting

  • Or 3 years of experience in a mental health or psychiatric care setting

Preferred Qualifications:

• Bachelor’s or Master’s Degree in Nursing (BSN/MSN)

• 2+ years experience in Medical Review, Utilization Management, or Case Management

• Prior experience in Managed Care

• Certified Case Manager (CCM) – Preferred

• Legal Nurse Consultant Certified (LNCC) – Preferred

Key Skill and Competencies:

• Strong ability to interpret and analyze clinical documentation and appeal requests

• Excellent written and verbal communication skills

• Proficiency in multi-platform systems for data review and documentation

• Ability to prioritize tasks and manage timelines in a high-volume setting

• Comfort in contacting and collaborating with provider offices and regulatory agencies

• Working knowledge of State and Federal regulations regarding healthcare appeals

Work Environment:

• Hybrid or remote environment depending on business needs

• Standard business hours with occasional extended hours based on case volume