Appeals Clinician I

Cambia Health Solutions; Boise (ID); Remote; USD 72,000 - 117,000; Full time

Benefits offered by this job

Health benefits

Annual HSA contributions

401(k) with company match

Paid time off

Job summary

Cambia Health Solutions is seeking an Appeals Clinician I to evaluate and resolve member/provider appeals using nursing expertise. This role supports compliance with medical policy, reimbursement rules, and regulatory standards while collaborating with physician advisers.

Ideal candidates hold a Bachelor’s in Nursing with at least 3 years of clinical experience, and an unrestricted RN license in OR/WA/ID/UT. Remote work is available with location-based pay ranges.

Qualifications

• 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 RN licensure in good standing in OR, WA, ID or UT and current unrestricted RN license.

Responsibilities

• Apply nursing expertise to ensure written appeal decisions comply with medical policy and related guidelines.
• Conduct clinical appeal reviews following member benefits and contracts.
• Consult with physician advisers to ensure clinically appropriate determinations when required.
• Educate non-clinical appeals staff on clinical cases.

Skills

Claim review

Medical policy knowledge

CPT coding

ICD-9 coding

HCPCS coding

MCG

Microsoft Word

Excel

PowerPoint

Access

AI tools

Education

Bachelor's Degree in Nursing

Tools

Microsoft Word

Excel

PowerPoint

Access

Job description

Appeals Clinician I

Work from home within Oregon, Washington, Idaho or Utah Preference will be given to current employees and candidates who reside in Idaho and Utah Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system.

Who We Are Looking For:

Every day, Cambia’s dedicated team of Appeals Clinicians are living our mission to make health care easier and lives better. As a member of the Clinical Services team, our Appeals Clinician I utilizes clinical expertise to complete the clinical component of all appeal types to resolve member and/or provider appeals – all in service of making our members’ health journeys easier. What if your clinical expertise could advocate for patients beyond the beside - shaping the outcomes that matter most to them? Are you an RN who finds yourself asking 'why' when a care decision doesn't feel right - and wishing you had the power to change it? Then this role may be the perfect fit.

Qualifications:

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 that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline (e.g. medical vs. behavioral health) and at least 3 years (or full time equivalent) of direct clinical care Registered nurse (RN) license (must have a current unrestricted RN license within either Oregon, Washington, Idaho or Utah).

Skills and Attributes:

Demonstrated competency in claim review and experience using billing and claims forms. Proven knowledge of medical and surgical procedures and other healthcare practices. Proven competency to apply clinical expertise to ensure compliance with medical policy. Familiarity regarding rules applied to appeals by accrediting bodies, state and federal governments, and employer groups. Knowledge in reading and interpreting medical records, patient data, and member benefits with an ability to communicate complex topics effectively with clinical and non-clinical staff. Knowledge of personal computer software, such as Microsoft Word, Excel, PowerPoint and Access. Ability to prepare and present clear and concise written narratives and decisions. Knowledge of CPT, ICD-9 and HCPCS coding and MCG (Milliman Care Guidelines). Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired.

What You Will Do at Cambia:

Applies nursing expertise and clinical judgement to ensure written appeal decisions are in compliance with medical policy, medical necessity guidelines, reimbursement policies, federal regulation, company policy, industry standard and accepted standards of care. Conducts clinical appeal reviews which adhere to member benefits and provider and hospital contracts. Consults with physician advisers to ensure clinically appropriate determinations when required. Advises and educates non-clinical appeals staff on clinical cases. #LI-Remote Pay ranges vary based on the candidate's work location. The expected hiring range depends on skills, experience, education, and training; relevant licensure / certifications; and performance history. Oregon, Washington, Utah, and Idaho: The expected hiring range is$36.80 - $49.80, the full salary range is$34.60 - $56.30 and the bonus target is 8%.

About Cambia

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.

Why Join the Cambia Team?

At Cambia, you can: Work alongside diverse teams building cutting-edge solutions to transform health care. Earn a competitive salary and enjoy generous benefits while doing work that changes lives. Grow your career with a company committed to helping you succeed. Give back to your community by participating in Cambia-supported outreach programs. Connect with colleagues who share similar interests and backgrounds through our employee resource groups. We believe a career at Cambia is more than just a paycheck – and your compensation should be too. Our compensation package includes competitive base pay as well as a market-leading 401(k) with a significant company match, bonus opportunities and more. In exchange for helping members live healthy lives, we offer benefits that empower you to do the same.

Just a few highlights include:

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
• Award-winning wellness programs that reward you for participation.
• Employee Assistance Fund for those in need.
• Commute and parking benefits.
• Learn more about our benefits.

We are happy to offer work from home options for most of our roles. To take advantage of this flexible option, we require employees to have a wired internet connection that is not satellite or cellular and internet service with a minimum upload speed of 5Mb and a minimum download speed of 10 Mb. As part of our security requirements, new hires will need access to a personal mobile device to set up Multi-Factor Authentication (MFA) upon joining the company. MFA is an important layer of protection for accessing Cambia systems and is required for all employees.

We are an Equal Opportunity employer dedicated to a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required. If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambia.

Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy.

Cambia Health Solutions is a family of companies headquartered in Portland, Oregon, working to make healthcare simpler, more affordable, and more person-focused. Through our regional health insurance plans, innovative technologies and strategic investments, we are delivering consumer-centric solutions that:

• Help people achieve better health and well-being
• Make healthcare more available, affordable, and personalized
• Are easily understood by everyone

We put people at the heart of everything we do. Our company reaches more than 70 million Americans nationwide, including more than 6 million people enrolled in our regional health plans. Cambia blends data science with a compassionate human perspective to anticipate people’s needs, and empower them to make smarter health care choices.

Interested in driving accessibility, affordability and quality health care for real people?