Remote Clinical Appeals Nurse: Influence Benefits

Zachary Piper Solutions; United States; Remote; USD 34,000 - 48,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

Sick leave as required by law

401K

Job summary

Piper Companies seeks a Clinical Appeals Nurse to join a leading health insurance organization for a contract remote opportunity based in North Carolina. The nurse will serve as a clinical resource within the appeals team, review complex cases, ensure regulatory compliance, and support accurate benefit determinations.

The role requires NC RN license with 3 years of clinical experience (or NC LPN/PT/OT with 5+ years).

Qualifications

• Active RN license in North Carolina with at least 3 years of clinical experience.
• OR active North Carolina licensure as an LPN, Physical Therapist (PT), or Occupational Therapist (OT) 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 with the ability to manage multiple priorities.

Responsibilities

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

Skills

RN license NC

LPN/PT/OT NC license

Healthcare appeals experience

Regulatory knowledge

Analytical skills

Communication skills

Problem-solving

Job description

Piper Companies seeks a Clinical Appeals Nurse to join a leading health insurance organization for a contract remote opportunity based in North Carolina. The nurse will serve as a clinical resource within the appeals team, review complex cases, ensure regulatory compliance, and support accurate benefit determinations.

The role requires NC RN license with 3 years of clinical experience (or NC LPN/PT/OT with 5+ years).