Remote Appeals Clinician I (RN) – Patient Advocate

Cambia Health

Bluffdale (UT)

Remote

USD 51,000 - 69,000

Full time

14 days+

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Benefits offered by this job

Medical, dental and vision coverage

Health savings account

Paid time off

Company 401(k) match

Job summary

Cambia Health is seeking an Appeals Clinician I to evaluate and finalize clinical appeals across multiple jurisdictions. You will apply nursing judgment and medical policy to ensure compliant decisions, partnering with physicians as needed.

Role requires a current RN license and 3+ years of direct clinical care in healthcare or insurance settings. Flexible remote work options are available with payscales reflecting location and licensure.

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.
Registered nurse (RN) license (must have a current unrestricted RN license within either Oregon, Washington, Idaho or Utah)

Responsibilities

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.