Remote RN Appeals Clinician I — Shape Care Decisions

Cambia Health Solutions; Salem (OR); Remote; USD 106,626,000 - 144,417,000; Full time

Job summary

Cambia Health Solutions is seeking an Appeals Clinician I to work remotely within Oregon, Washington, Idaho or Utah. The role focuses on applying nursing expertise to complete the clinical component of all appeal types and resolve member or provider appeals, helping to make health journeys easier.

You will collaborate with physician advisers and educate non-clinical staff on clinical cases, ensuring compliance with medical policy and regulations, while advocating for patients in complex

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, ... and at least 3 years (or full time equivalent) of direct clinical care
• 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.

Skills

RN license

Clinical review

Medical coding

Policy compliance

Communication

Education

Bachelor's Degree in Nursing

Tools

Microsoft Word

Excel

PowerPoint

Access

Job description

Cambia Health Solutions is seeking an Appeals Clinician I to work remotely within Oregon, Washington, Idaho or Utah. The role focuses on applying nursing expertise to complete the clinical component of all appeal types and resolve member or provider appeals, helping to make health journeys easier.

You will collaborate with physician advisers and educate non-clinical staff on clinical cases, ensuring compliance with medical policy and regulations, while advocating for patients in complex