North Carolina Licensed Clinical Appeals Nurse

Job Summary

To support a leading health insurance organization, the remote Clinical Appeals Nurse will review complex member and provider appeals, ensure regulatory compliance, and provide clinical guidance to the appeals team while working closely with internal stakeholders and providers.

Key responsibilities:

• Evaluate complex member and provider appeals by reviewing clinical records and regulatory requirements
• Provide clinical guidance to non-clinical appeals staff throughout the review and resolution process
• Identify appeal trends and recommend process improvements to enhance operational efficiency

Required qualifications:

• Active Registered Nurse (RN) license in North Carolina with at least 3 years of clinical experience, or active North Carolina licensure as an LPN, PT, or OT with 5+ years of clinical experience
• Strong understanding of healthcare appeals, grievance processes, and medical necessity reviews
• Experience interpreting clinical documentation and healthcare regulations
• Excellent analytical and organizational skills with the ability to manage multiple priorities