Appeals Clinician I

Cambia Health Solutions

. Complete the clinical component of all appeal types to resolve member and/or provider appeals .

Posted 9/29/2026full-timeRemote • United StatesMid-LevelSenior💰 $35 - $56 per hourWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in clinical appeal resolution, ensuring compliance with medical policies and regulations while effectively communicating complex clinical information to diverse audiences. Proficient in clinical care, claims review, and coding practices, with a strong foundation in nursing principles.

Highest-signal resume keywords

Bachelor's Degree In NursingCurrent Unrestricted Registered Nurse (RN) LicenseClinical Appeal ReviewClaims Review CompetencyKnowledge Of CPT, ICD-9, HCPCS Coding

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical JudgmentMedical Policy ComplianceMedical Record InterpretationBilling And Claims ReviewKnowledge Of Medical And Surgical ProceduresClinical Expertise ApplicationMulti-Factor AuthenticationAI Tools And Technologies

Soft Skills

Effective CommunicationEducation And Advising

Tools & Technologies

Microsoft WordMicrosoft ExcelMicrosoft PowerPointMicrosoft Access

Certifications & Qualifications

Active Licensure In Health Or Human Services Discipline

Industry Keywords

Healthcare PracticesAppeals RulesFederal RegulationsAccrediting BodiesMember Benefits

About the role

Key responsibilities & impact

Complete the clinical component of all appeal types to resolve member and/or provider appeals
Apply nursing expertise and clinical judgment to ensure written appeal decisions comply with medical policy, medical necessity guidelines, reimbursement policies, federal regulations, company policy, industry standards and accepted standards of care
Conduct clinical appeal reviews adhering to member benefits and provider and hospital contracts
Consult with physician advisers to ensure clinically appropriate determinations when required
Advise and educate non-clinical appeals staff on clinical cases

Requirements

What you’ll need

Bachelor's Degree in Nursing and 3 years of experience in a clinical setting, health insurance, coding/claims review, case management or equivalent combination of education and experience
Active licensure or certification in a state or territory of the United States in a health or human services discipline allowing independent assessment within scope of practice
At least 3 years (or full-time equivalent) of direct clinical care
Current unrestricted Registered Nurse (RN) license within Oregon, Washington, Idaho or Utah
Demonstrated competency in claim review and experience using billing and claims forms
Knowledge of medical and surgical procedures and healthcare practices
Competency applying clinical expertise to ensure compliance with medical policy
Familiarity with appeals rules applied by accrediting bodies, state and federal governments, and employer groups
Ability to read and interpret medical records, patient data and member benefits
Ability to communicate complex topics effectively with clinical and non-clinical staff
Knowledge of Microsoft Word, Excel, PowerPoint and Access
Ability to prepare and present clear, concise written narratives and decisions
Knowledge of CPT, ICD-9, HCPCS coding and MCG (Milliman Care Guidelines)
Experience with AI tools and technologies highly desired
Wired internet connection required; minimum 5 Mb upload and 10 Mb download speed; satellite or cellular connections not accepted
Personal mobile device required for Multi-Factor Authentication
Background check required

Benefits

Comp & perks

Competitive salary
Bonus opportunities
Market-leading 401(k) with a significant company match
Potential discretionary 401(k) contribution based on company performance with no vesting period
Medical, dental and vision coverage for employees and eligible family members, including mental health benefits
Annual employer contribution to a health savings account
Generous paid time off
10 company-paid holidays
Up to 12 weeks of paid parental time off, subject to eligibility
Award-winning wellness programs that reward participation
Employee Assistance Fund
Commute and parking benefits
Work from home options for most roles
Employee resource groups
Cambia-supported outreach programs
Career growth and professional development opportunities