Remote Clinical Appeals Nurse

ZP Group; United States; Remote; USD 34,000 - 48,000; 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 contract remote opportunity based in North Carolina. The nurse will serve as a clinical resource for the appeals team, reviewing complex cases and ensuring regulatory compliance to support accurate benefit determinations.

The role involves collaborating with providers, members, and internal stakeholders to facilitate timely appeal resolutions across lines of business, with responsibilities spanning review, documentation, and process

Qualifications

• Active RN license in North Carolina or LPN/PT/OT with 5+ years of clinical experience.
• 3+ years of clinical experience if RN; alternative licensure with 5+ years of clinical experience.
• Strong understanding of healthcare appeals, grievance processes, utilization management, and medical necessity reviews.
• Experience interpreting clinical documentation, insurance benefits, healthcare regulations, and medical policies.
• Excellent analytical, organizational, communication, and problem-solving skills.

Responsibilities

• Evaluate complex member and provider appeals by reviewing clinical records, policy guidelines, benefit plans, and regulatory requirements.
• Provide clinical guidance and consultation to non-clinical appeals staff throughout the review and resolution process.
• Obtain and assess medical documentation from providers and other external partners as needed.
• Present case findings and recommendations to physicians, leadership, and review committees while coordinating necessary claim adjustments.
• Identify appeal trends, compliance concerns, and operational issues, recommending process improvements.

Skills

RN license NC

Clinical experience 3+ years

Healthcare appeals

Utilization management

Medical necessity reviews

Analytical skills

Communication skills

Job description

Piper Companies is seeking a Clinical Appeals Nurse for a contract remote opportunity based in North Carolina. The nurse will serve as a clinical resource for the appeals team, reviewing complex cases and ensuring regulatory compliance to support accurate benefit determinations.

The role involves collaborating with providers, members, and internal stakeholders to facilitate timely appeal resolutions across lines of business, with responsibilities spanning review, documentation, and process