North Carolina Licensed Clinical Appeals Nurse

Job Summary

To support a leading health insurance organization, the remote Clinical Appeals Nurse will evaluate complex member and provider appeals, ensuring regulatory compliance and facilitating timely appeal resolutions while collaborating with internal stakeholders and external partners.

Key responsibilities:

• Evaluate complex member and provider appeals by reviewing clinical records and policy guidelines
• Provide clinical guidance to non-clinical appeals staff during 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 LPN/PT/OT with 5+ years of clinical experience
• Strong understanding of healthcare appeals, grievance processes, and utilization management
• Experience interpreting clinical documentation and healthcare regulations
• Excellent analytical and organizational skills with the ability to manage multiple priorities