Clinical Appeals Nurse (RN)

Talantir; Portland (OR); Remote; USD 90.000 - 120.000; Vollzeit

Benefits dieser Stelle

Medical insurance

Dental insurance

Vision insurance

Life insurance

Short/long-term disability

401(k) match

Zusammenfassung

VanderHouwen is seeking a detail-oriented Registered Nurse to lead clinical appeals reviews for members and providers, ensuring medical necessity alignment and high-quality determinations in a fully remote role across the Pacific Time zone.

The ideal candidate has 2+ years in health insurance or utilization management, 3+ years direct patient care, and strong command of medical terminology, CPT/ICD codes, and regulatory standards; proficiency with Microsoft Office and remote collaboration is

Qualifikationen

• Must hold a current, unrestricted Registered Nurse (RN) license in Oregon, Washington, Idaho, or Utah; Bachelor’s degree in Nursing preferred.
• Minimum of 2 years of experience in health insurance, utilization management, or clinical appeals review, plus at least 3 years of direct patient care experience.
• Strong knowledge of medical terminology, procedures, coding systems (CPT, ICD, HCPCS), and clinical guidelines (e.g., MCG).
• Proven ability to interpret medical records, claims, and benefit structures, and translate findings into clear, concise written determinations.
• Familiarity with regulatory and accreditation standards, along with proficiency in Microsoft Office tools and remote work environments.

Aufgaben

• Conduct comprehensive clinical reviews of member and provider appeals, ensuring alignment with medical necessity, policies, and standards of care.
• Apply clinical expertise to interpret medical records, benefit plans, and contractual requirements to support accurate determinations.
• Collaborate with physician advisors when needed to validate complex or high-risk clinical decisions.
• Ensure all appeal decisions meet regulatory, accreditation, and organizational compliance requirements.
• Provide guidance and education to non-clinical team members on clinical aspects of appeals and case reviews.

Kenntnisse

RN license

Clinical reviews

Medical terminology

Regulatory knowledge

Remote work

Ausbildung

Bachelor’s degree in Nursing

Tools

Microsoft Office

Jobbeschreibung

Our client is seeking a detail-oriented and clinically strong Registered Nurse who excels at applying sound judgment to complex healthcare scenarios. This individual will bring a balance of analytical thinking, regulatory awareness, and clear communication to ensure fair and accurate appeal outcomes. The ideal candidate is collaborative, adaptable, and confident navigating both clinical and non-clinical conversations in a remote environment.

Clinical Appeals Nurse (RN) Responsibilities

• Conduct comprehensive clinical reviews of member and provider appeals, ensuring alignment with medical necessity, policies, and standards of care.
• Apply clinical expertise to interpret medical records, benefit plans, and contractual requirements to support accurate determinations.
• Collaborate with physician advisors when needed to validate complex or high-risk clinical decisions.
• Ensure all appeal decisions meet regulatory, accreditation, and organizational compliance requirements.
• Provide guidance and education to non-clinical team members on clinical aspects of appeals and case reviews.

Clinical Appeals Nurse (RN) Qualifications

• Must hold a current, unrestricted Registered Nurse (RN) license in Oregon, Washington, Idaho, or Utah; Bachelor’s degree in Nursing preferred.
• Minimum of 2 years of experience in health insurance, utilization management, or clinical appeals review, plus at least 3 years of direct patient care experience.
• Strong knowledge of medical terminology, procedures, coding systems (CPT, ICD, HCPCS), and clinical guidelines (e.g., MCG).
• Proven ability to interpret medical records, claims, and benefit structures, and translate findings into clear, concise written determinations.
• Familiarity with regulatory and accreditation standards, along with proficiency in Microsoft Office tools and remote work environments.

This role is fully remote; applicants must reside in OR, WA, UT, or ID. Candidates must be able to work Pacific Time Zone hours and maintain flexibility to occasionally support work outside of standard business hours may be required.

Compensation: (DOE)

As an eligible contract employee with VanderHouwen, you'll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.

• medical
• dental
• vision
• life insurance
• short- and long-term disability
• a matching 401(k) to help secure your future

VanderHouwen is an Equal Opportunity Employer and participates in E-Verify. VanderHouwen does not discriminate based on race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable local, state, or federal civil rights laws.