Remote Appeals Clinician I - RN Advocate for Patients

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

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.