Clinical Appeals RN Job at IntelyCare (Cypress)

Appeals Nurse Consultant

This is a full-time telework position. Hours for this role are Monday-Friday 8a-...

Location

United States

Salary:

Not provided

CVS Health

Expiration Date

Until further notice

Requirements

Must have active and unrestricted RN licensure in state of residence
3+ years clinical experience

Job Responsibility

Responsible for the review and resolution of clinical appeals
Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues
Independently coordinates the clinical resolution with internal/external clinician support as required

Fulltime

Medical Appeals/Grievance Specialist II - Registered Nurse

Responsible for utilizing clinical acumen and managed care expertise related to ...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

1 year experience in clinical and health insurance or other healthcare related field
3 years experience in clinical and health insurance or other healthcare related field AND 1 year Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years experience in clinical and health insurance or other healthcare related field AND 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
8 years experience in clinical and health insurance or other healthcare related field AND 3 years above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Associate’s Degree in a healthcare field of study or Nursing Diploma
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW.
Intermediate PC proficiency
Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones
Maintain confidentiality and privacy
Advanced clinical knowledge

Job Responsibility

Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
Maintain complete and accurate records per department policy.
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
Demonstrate ability to apply plan policies and procedures effectively.
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.
Attend staff and interdepartmental meetings.
Participate in continuing education and current developments in the fields of medicine and managed care.

Fulltime

Appeals and Grievances Clinical Specialist

The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, griev...

Location

United States , New York City; Lake Mary

Salary:

73400.00 - 120360.00 USD / Year

Healthfirst

Expiration Date

Until further notice

Requirements

RN, LPN
Bachelor’s degree
Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management
Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines
Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system, (ie. Maces)
Experience with care management systems, such as CCMS, TruCare and Hyland
Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

Job Responsibility

Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services
Research issues
Reference and understand HF’s internal health plans policies and procedures to frame decisions
Interpret regulations
Resolve cases and make critical decisions
Update file documentation such as the file notes and case summary
Manage all duties within regulatory timeframes
Communicate effectively to hand-off and pick-up work from colleagues
Work within a framework that measures productivity and quality for each Specialist against expectations
Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case

What we offer

medical, dental and vision coverage
incentive and recognition programs
life insurance
401k contributions

Fulltime

Appeals and Grievances Clinical Specialist

The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, griev...

Location

United States , New York City; Lake Mary

Salary:

73400.00 - 120360.00 USD / Year

Healthfirst

Expiration Date

Until further notice

Requirements

RN, LPN OR Dental Hygienist
Bachelor’s degree
Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management
Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines
Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system, (ie. Macess)
Experience with care management systems, such as CCMS, TruCare and Hyland
Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

Job Responsibility

Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services
Research issues
Reference and understand HF’s internal health plans policies and procedures to frame decisions
Interpret regulations
Resolve cases and make critical decisions
Update file documentation such as the file notes and case summary
Manage all duties within regulatory timeframes
Communicate effectively to hand-off and pick-up work from colleagues
Work within a framework that measures productivity and quality for each Specialist against expectations
Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case

What we offer

medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions

Fulltime

Appeals and Grievances Clinical Specialist

The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, griev...

Location

United States , New York City; Lake Mary

Salary:

73400.00 - 120360.00 USD / Year

Healthfirst

Expiration Date

Until further notice

Requirements

RN, LPN OR Dental Hygienist
Bachelor’s degree
Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management
Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines
Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system, (ie. Macess)
Experience with care management systems, such as CCMS, TruCare and Hyland
Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

Job Responsibility

Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services
Research issues
Reference and understand HF’s internal health plans policies and procedures to frame decisions
Interpret regulations
Resolve cases and make critical decisions
Update file documentation such as the file notes and case summary
Manage all duties within regulatory timeframes
Communicate effectively to hand-off and pick-up work from colleagues
Work within a framework that measures productivity and quality for each Specialist against expectations
Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case

What we offer

medical, dental and vision coverage
incentive and recognition programs
life insurance
401k contributions

Fulltime

Appeals and Grievances Clinical Specialist

The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, griev...

Location

United States , New York City; Lake Mary

Salary:

73400.00 - 120360.00 USD / Year

Healthfirst

Expiration Date

Until further notice

Requirements

RN, LPN OR Dental Hygienist
Bachelor’s degree
Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management
Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines
Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system, (ie. Macess)
Experience with care management systems, such as CCMS, TruCare and Hyland
Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

Job Responsibility

Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services
Research issues
Reference and understand HF’s internal health plans policies and procedures to frame decisions
Interpret regulations
Resolve cases and make critical decisions
Update file documentation such as the file notes and case summary
Manage all duties within regulatory timeframes
Communicate effectively to hand-off and pick-up work from colleagues
Work within a framework that measures productivity and quality for each Specialist against expectations
Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case

What we offer

medical, dental and vision coverage
incentive and recognition programs
life insurance
401k contributions

Fulltime

Clinical Nurse Appeal Analyst

The Clinical Nurse Appeal Analyst is responsible for reviewing, analyzing, and r...

Location

United States , Madison

Salary:

57000.00 - 102000.00 USD / Year

Exact Sciences

Expiration Date

Until further notice

Requirements

Associates Degree in Nursing
3+ years of experience in clinical appeals, utilization review, or case management
Ability to work independently and manage multiple priorities
Familiarity with payer guidelines and medical necessity standards
Possession of active RN license at time of hire and maintain throughout employment in position
Demonstrated ability to perform the essential duties of the position with or without accommodation
Applicants must be currently authorized to work in country where work will be performed on a full or part-time basis

Job Responsibility

Review payer denials related to medical necessity, level of care, and clinical documentation
Analyze patient medical records to determine the appropriateness of care and services provided
Draft and submit timely, evidence-based clinical appeals to payers
Collaborate with physicians, case management, and coding teams to gather supporting documentation when needed
Monitor appeal outcomes and identify trends in denials to inform process improvements
Maintain up-to-date knowledge of payer guidelines, CMS regulations, and industry best practices
Educate revenue cycle and non-clinical staff on denial trends and documentation of improvement opportunities
Educate and support non-clinical staff on how to interpret medical policies and draft compelling arguments to overturn denials
Support clinical appeal strategy
Participate in denial management meetings and performance improvement initiatives

What we offer

Paid time off (including days for vacation, holidays, volunteering, and personal time)
Paid leave for parents and caregivers
A retirement savings plan
Wellness support
Health benefits including medical, prescription drug, dental, and vision coverage
Bonus eligibility

Fulltime

Lead Customer Solution Center Appeals and Grievances RN

The Lead Customer Solution Center Appeals and Grievances RN is responsible for a...

Location

United States , Los Angeles

Salary:

102183.00 - 163492.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing for Registered Nurses
At least 8 years of clinical appeals and grievances experience in a managed care, utilization management and/or case management setting
At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment
At least 1 year of leading a process, program, or staff experience
Extensive knowledge of healthcare regulations and managed care guidelines
Strong critical thinking and problem-solving abilities to assess complex clinical cases and evaluate medical necessity
Ability to communication, conflict resolution, and motivational skills
Ability to work independently and closely with a team in a collaborative and interactive environment
Ability to adjust to changing circumstances within the team
Good verbal and written communication skills

Job Responsibility

Assist with the development of a successful and cohesive Appeals and Grievance (A&G) clinical unit
Quality review of complex and/or escalated clinical A&G cases for all line of business (LOB)
Assist in identifying areas of improvement in increasing positive audit outcomes and improved Customer Service
Ensure the effective investigation and resolution of clinical grievances, appeals, complaints, and complex issues in alignment with L.A. Care policy and procedures and regulatory guidelines
Lead and work closely with assigned team daily
Mentor, coach, and may provide feedback to management on performance of staff
Review and process complex and/or escalated clinical A&G cases
Analyze patient medical records, clinical documentation, and insurance policies to determine medical necessity
Prepare and review A&G files for submission to providers and internal departments
Work with other departments to ensure all aspects of a case are appropriately managed

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Clinical Appeals RN

IntelyCare

Location:
United States , Cypress

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
January 10, 2026

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