Clinical Appeals Leader — Optimize Reimbursement (CA)

Orthofix Medical; Carlsbad (CA); On-site; USD 122,000 - 149,000; Full time

Job summary

Orthofix Medical in Carlsbad, CA is seeking a licensed nurse to oversee and continuously improve the clinical appeals function. The role applies clinical judgment to evaluate payer denials, devising appeal strategies and ensuring timely submissions.

You will collaborate across departments to address documentation, authorization, and reimbursement issues while driving process improvements. The ideal candidate has 6+ years in clinical appeals or related areas, strong writing of appeal narratives,

Qualifications

• Active, unrestricted license as a Registered Nurse (RN) or Licensed Vocational Nurse (LVN) in California.
• Graduate of an accredited nursing program.
• Current credentials and continuing education required to maintain California licensure.

Responsibilities

• Lead the daily clinical appeals workflow, including intake, denial classification, appeal eligibility review, prioritization, assignment, submission, follow-up, escalation, and closure.
• Perform licensed clinical review of payer denials and supporting records to determine the clinical issue, documentation gap, applicable coverage requirement, and appropriate appeal pathway.
• Develop or oversee accurate, patient-specific appeal narratives that connect the clinical record, payer policy, medical necessity criteria, and supporting evidence without creating or altering treating-provider documentation.
• Compile complete appeal packages, including orders, clinical notes, certificates of medical necessity, payer correspondence, authorization records, policy excerpts, and other required documentation.
• Monitor payer‑specific filing deadlines, appeal levels, submission requirements, aging, and status to reduce avoidable untimely or incomplete submissions.
• Establish standardized appeal templates, evidence checklists, case documentation standards, quality controls, and escalation rules.
• Create and maintain an appeals dashboard illustrating volume, aging, submission timeliness, overturn outcomes, denial category, payer trends, and dollars recovered or preserved.
• Identify recurring clinical, documentation, policy, authorization, coding, or process issues observed through appeals and communicate findings to the appropriate functional owner.
• Partner with the Senior Manager, Payer and Documentation Audits on documentation trends, audit support, and opportunities identified through appeals. Provide appeal data and clinical insight while preserving that function's ownership of audit strategy and enterprise revenue leakage initiatives.
• Collaborate with Sales Administration, Accounts Receivables, Payer Contracting, Legal, Compliance, Medical Affairs, Sales, and field teams to resolve case‑specific barriers and improve appeal readiness.
• Support payer escalations, reconsiderations, peer‑to‑peer preparation, administrative hearings, and external review activities as permitted by applicable law, payer rules of practice.
• Provide practical education and feedback to internal stakeholders on payer clinical criteria, medical necessity documentation, common denial drivers, and appeal package requirements.
• Support California DME licensure, inspection readiness, policy maintenance, and other clinical oversight activities assigned to the licensed professional for the California office.
• Maintain current knowledge of applicable payer policies, Medicare and Medicaid requirements, California requirements, company policies, and professional licensure obligations.
• Maintain regular and reliable attendance at the designated Orthofix California office.
• Performs other duties as assigned

Skills

Clinical appeals

Payer denial reviews

Documentation

Communication skills

MS Office

Education

RN or LVN license in CA

California licensure

Nursing degree

Tools

Microsoft Word

Excel

PowerPoint

Case tracking systems

Job description

Orthofix Medical in Carlsbad, CA is seeking a licensed nurse to oversee and continuously improve the clinical appeals function. The role applies clinical judgment to evaluate payer denials, devising appeal strategies and ensuring timely submissions.

You will collaborate across departments to address documentation, authorization, and reimbursement issues while driving process improvements. The ideal candidate has 6+ years in clinical appeals or related areas, strong writing of appeal narratives,