Clinical Appeals Nurse - 171208

ZP Group; North Carolina; Remote; USD 70,000 - 80,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

401K

Job summary

Piper Companies is seeking a Clinical Appeals Nurse for a fully remote, long-term contract in the healthcare sector. The role focuses on clinical review, appeal resolution, regulatory compliance, and member/provider support within a complex health insurance environment.

Requirements include an active NC RN license with 3+ years of clinical experience (or NC LPN/PT/OT with 5+ years), strong knowledge of healthcare regulations, and demonstrated ability to handle confidential medical documentation

Qualifications

• Active RN license in North Carolina with a minimum of three years of clinical experience; OR active LPN, PT, or OT license in North Carolina with at least five years of clinical experience.
• Strong understanding of healthcare regulations, medical necessity review standards, utilization management principles, and appeals processes.
• Experience reviewing medical documentation and applying clinical judgment in support of coverage or reimbursement determinations.
• Excellent written and verbal communication skills with the ability to present clinical findings to both technical and non-technical audiences.
• Proven ability to manage multiple priorities, maintain accuracy in a deadline-driven environment, and work independently in a remote setting.

Responsibilities

• Evaluate complex appeal and grievance cases by interpreting clinical guidelines, benefit language, regulatory requirements, and coverage policies to support fair and accurate determinations.
• Serve as a clinical resource for non-clinical team members, offering guidance throughout the appeal review process and ensuring adherence to established standards.
• Gather and assess supporting medical records and documentation from healthcare providers, legal representatives, outside organizations, and other relevant sources.
• Prepare case summaries and recommendations for physician reviewers, leadership teams, and review committees, while facilitating necessary claim corrections and adjustments.
• Respond to member and provider inquiries, identify process improvement opportunities, and help develop corrective actions related to benefits interpretation, policy application, or claims processing issues.

Skills

Clinical review

Appeals process

Regulatory compliance

Medical necessity review

Communication skills

Education

RN license in North Carolina

LPN/PT/OT license in North Carolina

Job description

Piper Companies is seeking a Clinical Appeals Nurse for a fully remote healthcare-based opportunity. This Clinical Appeals Nurse position is a long-term contract role focused on clinical review, appeal resolution, regulatory compliance, and member/provider support within a complex health insurance environment.

Responsibilities

• Evaluate complex appeal and grievance cases by interpreting clinical guidelines, benefit language, regulatory requirements, and coverage policies to support fair and accurate determinations.
• Serve as a clinical resource for non-clinical team members, offering guidance throughout the appeal review process and ensuring adherence to established standards.
• Gather and assess supporting medical records and documentation from healthcare providers, legal representatives, outside organizations, and other relevant sources.
• Prepare case summaries and recommendations for physician reviewers, leadership teams, and review committees, while facilitating necessary claim corrections and adjustments.
• Respond to member and provider inquiries, identify process improvement opportunities, and help develop corrective actions related to benefits interpretation, policy application, or claims processing issues.

Qualifications

• Active Registered Nurse (RN) license in the State of North Carolina with a minimum of three years of clinical experience; OR active LPN, Physical Therapist (PT), or Occupational Therapist (OT) license in North Carolina with at least five years of clinical experience.
• Strong understanding of healthcare regulations, medical necessity review standards, utilization management principles, and appeals processes.
• Experience reviewing medical documentation and applying clinical judgment in support of coverage or reimbursement determinations.
• Excellent written and verbal communication skills with the ability to present clinical findings to both technical and non-technical audiences.
• Proven ability to manage multiple priorities, maintain accuracy in a deadline-driven environment, and work independently in a remote setting.

Compensation

Salary Range: $70,000 - $80,000 annually

Comprehensive Benefits: Medical, Dental, Vision, sick leave if required by law, and 401K

Application Details

• Posting Date: August 7, 2026
• Apply By Date: August 31, 2026
• Work Arrangement: Fully Remote
• Employment Type: Long-Term Contract

Keywords

Clinical Appeals Nurse, Appeals and Grievances, Medical Necessity Review, Utilization Management, Case Review, Health Insurance, Managed Care, NCQA, Regulatory Compliance, Clinical Documentation, Healthcare Appeals, Member Advocacy, Provider Relations, Coverage Determinations, Claims Review, Registered Nurse, RN, LPN, Physical Therapist, Occupational Therapist, Healthcare Policy, Benefit Interpretation, Clinical Analysis, Medical Records Review, Grievance Resolution, Quality Assurance, Medicare, Medicaid, Physician Review, Remote Nursing, Healthcare Operations, Claims Adjustment, Appeals Coordination, Utilization Review, Clinical Consulting, Healthcare Compliance, Case Management, Patient Advocacy, Health Plan Operations, Managed Healthcare

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