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

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

Medicare Audit & Appeals Supervisor

As the Medicare Audit & Appeals Supervisor for Baxter Respiratory Health team, y...

Location

United States , Saint Paul

Salary:

68000.00 - 93500.00 USD / Year

Baxter

Expiration Date

Until further notice

Requirements

Respiratory Therapist (RT), Licensed Practical Nurse (LPN), or Registered Nurse (RN) or Paralegal required
Current professional licensure or certification as required by the state of residence
3+ years’ experience in Medicare Audits, Medical Claims, Appeals or Third-Party Reimbursement
1+ years leadership or supervisory experience
Strong critical thinking and problem-solving skills
Knowledge of the various contractors Medicare Fee for Service audits, preferred
Knowledge of Medicare Regulations preferred
Experience with Third Party Compliance preferred
Experience with Durable Medical Equipment provider preferred
Six Sigma Green Belt preferred

Job Responsibility

Directly supervise assigned staff, including on-going performance feedback
Apply corrective measures as appropriate to ensure standards are maintained and goals are achieved
Provide work direction and content expertise to direct reports
Supervise medical reimbursement including Clinical Review for coverage and Medicare Appeals
Prepare and submit pre- and post-payment Audits to Medicare programs
Evaluate and process daily adjustment requests as needed
Assist staff in career development and training
Provide training and mentorship to new team members
Monitor workloads, including daily performance metrics, overdue activities and pending files
Identify and resolve issues on complex patient files

What we offer

Medical and dental coverage starting on day one
Insurance coverage for basic life, accident, short-term and long-term disability, and business travel accident insurance
Employee Stock Purchase Plan (ESPP)
401(k) Retirement Savings Plan with employee contributions and company matching
Flexible Spending Accounts
Educational assistance programs
Paid holidays
Paid time off ranging from 20 to 35 days based on length of service
Family and medical leaves of absence
Paid parental leave

Fulltime

Medicare Audit & Appeals Supervisor

Supervise employees in the Revenue Cycle Management function while acting as a r...

Location

United States , Saint Paul

Salary:

5666.67 - 7791.67 USD / Month ▼

Baxter

Expiration Date

Until further notice

Requirements

Respiratory Therapist (RT), Licensed Practical Nurse (LPN), or Registered Nurse (RN) or Paralegal required
Current professional licensure or certification as required by the state of residence
3+ years’ experience in Medicare Audits, Medical Claims, Appeals or Third-Party Reimbursement
1+ years leadership or supervisory experience
Strong critical thinking and problem-solving skills
Knowledge of the various contractors Medicare Fee for Service audits, preferred
Knowledge of Medicare Regulations preferred
Experience with Third Party Compliance preferred
Experience with Durable Medical Equipment provider preferred
Six Sigma Green Belt preferred

Job Responsibility

Directly supervise assigned staff, including on-going performance feedback
Apply corrective measures as appropriate to ensure standards are maintained and goals are achieved
Provide work direction and content expertise to direct reports
Supervise medical reimbursement including Clinical Review for coverage and Medicare Appeals
Prepare and submit pre- and post-payment Audits to Medicare programs
Evaluate and process daily adjustment requests as needed
Assist staff in career development and training
Provide training and mentorship to new team members
Monitor workloads, including daily performance metrics, overdue activities and pending files
Identify and resolve issues on complex patient files

What we offer

Medical and dental coverage starting on day one
Basic life insurance
Accident insurance
Short-term and long-term disability insurance
Business travel accident insurance
Employee Stock Purchase Plan (ESPP)
401(k) Retirement Savings Plan with company matching
Flexible Spending Accounts
Educational assistance programs
Paid holidays

Fulltime

Manager, Utilization Management

The Utilization Management (UM) team at UVM Health is searching for a UM Manager...

Location

United States

Salary:

46.89 - 70.34 USD / Hour

The University of Vermont Health Network

Expiration Date

Until further notice

Requirements

Bachelor’s Degree in Nursing required
Master’s degree in nursing or experience equivalent preferred
Current and Active Registered Nurse (RN) license
CM certification preferred
Case management accreditation required by a nationally recognized accrediting body for case management (examples: CCM, ACM or ANCC certifications), preferred
Experience working within a unionized environment preferred
3-5 years of leadership experience in a healthcare setting required
3-5 years of clinical experience in a healthcare setting (or equivalent) required
Care Management/Care Coordination experience required

Job Responsibility

Leads teams responsible for oversight of staff and daily operations within the Utilization Management (UM) department
Provides training, guidance, and support to direct reports
Ensures regulatory compliance
Contributes to UM programming across the UVM Health
Ensures quality outcomes in medical necessity review, appeals, denials, and patient status determination
Coaches and mentors team members to enhance performance
Promotes a positive work environment that supports staff engagement
Leads change initiatives
Encourages professional development and continuous learning
Communicates complex clinical requirements clearly to staff and stakeholders

What we offer

Comprehensive, total compensation package that includes salary, health and wellness benefits, paid time off, and more

Fulltime

New

Investment Banking Vice President, COO Office

Embark on a transformative journey as an Investment Banking VP, COO Office. At B...

Location

United Kingdom , London

Salary:

Not provided

Barclays

Expiration Date

Until further notice

Requirements

Experience with strategy, management consulting, investment banking, or strategy roles within a leading financial institution
Core banking and financial services performance drivers, risk management principles, and regulatory frameworks
Supporting multi-layered projects, managing multiple workstreams, and delivering high-quality outcomes under tight deadlines
Engaging, influencing, and collaborating with senior stakeholders, including Managing Director–level audiences
Operating effectively in fast-paced, high-expectation environments

Job Responsibility

Collaboration with business and senior leadership to develop and implement business strategies that align with organizational goals and regulatory requirements
Liaison between different business units and functions, fostering communication and collaboration
Management and coordination of strategic initiatives, projects, and change management efforts to optimize business processes and strengthen the control environment
Improvement of operational efficiency within the organisation including the identification of areas for improvement, streamlining of processes, and implementation of best practices to enhance productivity and effectiveness
Development of performance reporting for key metrics that reinforce the strategic objectives of the division and support the external commitments made
Involvement in aspects of financial analysis and budget management, including assistance in financial planning, forecasting, and monitoring of financial performance against targets
Support to business heads in partnership with HR on hiring, workforce planning, joiner/mover/leaver actions

What we offer

Hybrid working
Flexible working arrangements
Supportive and inclusive culture and environment
Opportunity to embrace mobility and explore operations

Fulltime

New

Entry-Level Labor

Entry-level position with opportunity to learn and explore many jobs within the ...

Location

United States , Quincy

Salary:

22.84 USD / Hour

Sierra Pacific Industries

Expiration Date

February 14, 2026

Requirements

Recent, related work history
Verifiable references
Must be at least age 18

Job Responsibility

Learn to fill in on various machine stations
Shovel, rake, and sweep wood byproducts
Stack and pile lumber

What we offer

Up to $1,500 hiring bonus
We train and promote from within
Excellent low-cost health benefits
Retirement plan with employer-paid contributions
Paid vacation
10 holidays
Full Health Benefits Plan (medical, dental, vision) with low-cost premiums
401(k) with Company Match
Additional Retirement Contributions
Company-paid Life Insurance

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

Looking for more opportunities? Search for other job offers that match your skills and interests.

Similar Jobs for Clinical Appeals RN

Appeals Nurse Consultant

Medical Appeals/Grievance Specialist II - Registered Nurse

Lead Customer Solution Center Appeals and Grievances RN

Medicare Audit & Appeals Supervisor

Medicare Audit & Appeals Supervisor

Manager, Utilization Management

Investment Banking Vice President, COO Office

Entry-Level Labor

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

Looking for more opportunities? Search for other job offers that match your skills and interests.

Similar Jobs for Clinical Appeals RN

Appeals Nurse Consultant

Medical Appeals/Grievance Specialist II - Registered Nurse

Lead Customer Solution Center Appeals and Grievances RN

Medicare Audit & Appeals Supervisor

Medicare Audit & Appeals Supervisor

Manager, Utilization Management

Investment Banking Vice President, COO Office

Entry-Level Labor

Location:
United States , Cypress

Category:
Nursing

Contract Type:
Not provided

Job Posted:
January 10, 2026