RN Clinical Appeals Strategist

Independence Blue Cross; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

Independence Blue Cross is seeking a Clinical Appeals Coordinator, RN to manage end-to-end clinical appeals including medical necessity, benefit, pharmacy, and behavioral health issues. You will apply nursing judgment, utilization management knowledge, and evidence-based criteria to ensure timely, compliant reviews.

This role serves as a clinical resource to Appeals Specialists, team leads, supervisors, and medical directors, supporting case development, outreach, and audit-ready file

Qualifications

• Active, unrestricted RN license required.
• Minimum five years of clinical nursing experience.
• Experience in utilization management and appeal processing.
• Knowledge of NCQA standards and appeal regulations.
• Ability to review medical records and documentation.

Responsibilities

• Manage assigned clinical appeals from intake through resolution.
• Review appeal files for completeness and accuracy.
• Apply clinical nursing knowledge to support classification and handling.
• Coordinate matched-specialty reviews and committee support.
• Prepare clear member/provider communications.

Skills

Registered Nurse

Utilization management

Clinical documentation

Evidence-based review

Strong communication

Tools

Microsoft Office

EMR systems

Appeal systems

Job description

Independence Blue Cross is seeking a Clinical Appeals Coordinator, RN to manage end-to-end clinical appeals including medical necessity, benefit, pharmacy, and behavioral health issues. You will apply nursing judgment, utilization management knowledge, and evidence-based criteria to ensure timely, compliant reviews.

This role serves as a clinical resource to Appeals Specialists, team leads, supervisors, and medical directors, supporting case development, outreach, and audit-ready file