Senior Clinical Appeals Lead - RN (CA)

orthofix; Carlsbad (CA); On-site; USD 110,000 - 140,000; Full time

Job summary

Orthofix in California is seeking an experienced Clinical Appeals Specialist to oversee and improve the payer denial appeals process. You will lead daily workflows, review records, and craft patient-specific appeal narratives that align with medical necessity and payer policies.

This role requires an active CA RN or LVN license, 6+ years in clinical appeals or related areas, and the ability to partner with cross-functional teams to reduce revenue risk and ensure timely submissions.

Qualifications

• Active, unrestricted CA license as RN or LVN.
• Graduate of an accredited nursing program.
• Current credentials and continuing education required to maintain CA licensure.
• Minimum of six years of clinical appeals or related healthcare experience.

Responsibilities

• Lead daily clinical appeals workflow including intake, denial classification, and submission follow-up.
• Perform licensed clinical review of payer denials to determine issues and pathways.
• Develop patient-specific appeal narratives connecting medical record, payer policy, and medical necessity.
• Assemble complete appeal packages with necessary documentation and authorization records.
• Monitor filing deadlines, levels, and aging to ensure timely submissions.
• Establish standardized templates, checklists, and quality controls for appeals.

Skills

Clinical appeals

Denials review

Payer policy interpretation

Medical Records review

Education

CA RN license

CA LVN license

Graduation from accredited nursing program

Job description

Orthofix in California is seeking an experienced Clinical Appeals Specialist to oversee and improve the payer denial appeals process. You will lead daily workflows, review records, and craft patient-specific appeal narratives that align with medical necessity and payer policies.

This role requires an active CA RN or LVN license, 6+ years in clinical appeals or related areas, and the ability to partner with cross-functional teams to reduce revenue risk and ensure timely submissions.