RN Clinical Appeals Leader - Reimbursement Strategy

Caris MPI, Inc.; Irving (TX); On-site; USD 110,000 - 140,000; Full time

Job summary

Caris Life Sciences is seeking a clinically experienced and strategically minded Clinical Claims Appeals Manager who is an RN, preferably bachelor's prepared, with direct health insurance company experience in clinical appeals and utilization management.

You will develop and execute second-level appeal strategies for complex denials, focusing on determinations that Caris testing is not medically necessary, combining nursing judgment, policy analysis, and evidence-based argumentation.

Qualifications

• Active RN license in good standing.
• BSN or equivalent degree.
• 5+ years in clinical appeals or payer functions.
• Experience with health insurance companies.
• Leadership or project leadership experience.
• Strong clinical-writing and analytic skills.

Responsibilities

• Develop and execute second-level appeal strategies.
• Lead escalation and peer discussions with payers.
• Create standardized appeal templates and evidence.
• Maintain centralized appeal library.
• Provide reporting on appeal outcomes.
• Mentor nursing staff in appeals.

Skills

RN clinical appeals

Leadership experience

Medical necessity review

Payer strategy writing

Clinical documentation

Communication with payers

Education

BSN or higher

Registered Nurse license

Tools

Epic

Microsoft Word

Excel

Job description

Caris Life Sciences is seeking a clinically experienced and strategically minded Clinical Claims Appeals Manager who is an RN, preferably bachelor's prepared, with direct health insurance company experience in clinical appeals and utilization management.

You will develop and execute second-level appeal strategies for complex denials, focusing on determinations that Caris testing is not medically necessary, combining nursing judgment, policy analysis, and evidence-based argumentation.