RN Clinical Appeals Specialist

Independence Blue Cross; United States; Remote; USD 80,000 - 115,000; Full time

Job summary

Independence Health Group (IBX) is seeking a Clinical Appeals Coordinator, RN to manage end-to-end clinical appeals, applying nursing judgment and utilization management principles. You will coordinate multidisciplinary reviews, ensure documentation quality, and prepare correspondence with members and providers.

The role emphasizes regulatory compliance, audit readiness, and collaboration across cross-functional teams.

Qualifications

• Active, unrestricted RN license.
• Five years of clinical nursing or healthcare experience.
• Experience in utilization management or appeal processing.
• Knowledge of NCQA standards and state/federal appeal regulations.
• Familiarity with InterQual or MCG criteria.
• Strong written and verbal communication skills.
• Ability to work independently and manage competing priorities.
• Excellent time-management and organizational abilities.

Responsibilities

• Manage assigned clinical appeals from intake through resolution, including case review, outreach, documentation gathering, and coordination.
• Review appeal files to ensure all required documentation is complete and accurate.
• Apply nursing knowledge, UM principles, and evidence-based criteria to support appropriate classification and handling.
• Determine whether issues involve medical necessity, benefit coverage, administrative processing, pharmacy, behavioral health, or regulatory concerns, escalating complex cases.
• Coordinate matched-specialty reviews, peer review, and committee preparation as required.
• Review investigations, case summaries, and provider/member communications for accuracy and compliance.
• Prepare and support clear written correspondence to members, providers, and authorized representatives.
• Ensure appeal files are audit-ready with documentation of investigation, review, and determinations.
• Monitor appeal inventory and turnaround times to comply with regulatory requirements.
• Support policy, workflow, or accreditation changes affecting clinical appeal processing.
• Identify trends and opportunities for process improvement and provider education.
• Participate in department training, quality reviews, and continuous improvement initiatives.

Skills

RN license

Utilization management

Appeal processing

NCQA knowledge

InterQual/MCG familiarity

Communication skills

Independent work

Time management

Audit readiness

Collaboration

Education

BSN

Tools

Microsoft Office

Appeal systems

Clinical documentation systems

Claims systems

Utilization management platforms

Databases

Spreadsheets

Job description

Independence Health Group (IBX) is seeking a Clinical Appeals Coordinator, RN to manage end-to-end clinical appeals, applying nursing judgment and utilization management principles. You will coordinate multidisciplinary reviews, ensure documentation quality, and prepare correspondence with members and providers.

The role emphasizes regulatory compliance, audit readiness, and collaboration across cross-functional teams.