Remote RN Appeals Clinician I

Cambia Health; Boise (ID); Remote; USD 48,000 - 79,000; Full time

Benefits offered by this job

Work from home option

Competitive salary with bonus

Paid time off and holidays

401(k) with company match

Wellness programs

Employee assistance fund

Job summary

Cambia Health seeks an Appeals Clinician I to evaluate member and provider appeals using nursing expertise and clinical judgment. This remote role supports multiple states and emphasizes medical policy, reimbursement guidelines, and compliance.

Responsibilities include conducting reviews, consulting with physician advisers, and educating non-clinical staff while ensuring timely, high-quality decisions in line with policy and industry standards.

Qualifications

• Bachelor's degree in Nursing and 3 years of clinical or related experience.
• Active RN licensure in OR, WA, ID or UT.
• Experience in claims review, medical policy and coding systems.

Responsibilities

• Applies nursing expertise to ensure appeal decisions align with policy and guidelines.
• Conducts clinical appeal reviews adhering to benefits and contracts.
• Consults with physician advisers to ensure appropriate determinations.
• Advises and educates non-clinical appeals staff on clinical cases.

Skills

Nursing

RN license

Clinical experience

Medical policy knowledge

Reading medical records

Microsoft Word

CPT/ICD-9/HCPCS coding

Claims review

AI tools familiarity

Education

Bachelor's in Nursing

Tools

Microsoft Word

Excel

PowerPoint

Access

Job description

Cambia Health seeks an Appeals Clinician I to evaluate member and provider appeals using nursing expertise and clinical judgment. This remote role supports multiple states and emphasizes medical policy, reimbursement guidelines, and compliance.

Responsibilities include conducting reviews, consulting with physician advisers, and educating non-clinical staff while ensuring timely, high-quality decisions in line with policy and industry standards.