Job Title: Clinical Appeals Nurse

Location: OFFSITE

Type: Contract

Compensation: $44.50

Contractor Work Model: Remote

Licenses/Certifications:

Required: RN - Registered Nurse, State Licensure and/or Compact State Licensure
Preferred: CCM - Certified Case Manager, LNCC - Legal Nurse Consultant Certified

Position Summary:

TheClinical Appeals Nurse is responsible for investigating and evaluating member and provider disputes regarding adverse determinations and coverage decisions. This role involves clinical review, regulatory compliance, and written case documentation for appeals. The nurse leverages expert clinical knowledge along with applicable federal and state regulations governing the appeals process across commercial lines of business to ensure accurate, timely, and compliant responses.

Key Responsibilities:
- Investigate, interpret, and evaluate written appeals and reconsideration requests from members, providers, legal representatives, and internal stakeholders.
- Respond with clear, clinically informed, and regulatory-compliant decisions through technical and detailed correspondence.
- Maintain consistency with organizational policies while adhering to all applicable regulatory mandates.
- Compile relevant clinical records, benefit information, policies, and correspondence for physician reviewer evaluation.
- Formulate clinical recommendations and prepare written summaries for physician review.
- Communicate appeal outcomes and external appeal rights to members and providers in a clear and timely manner.
- Use clinical nursing expertise to assess the appropriateness of adverse decisions for both medical and behavioral health conditions.
- Review and apply internal medical policies and ensure adherence to federal/state regulatory and accreditation requirements.
- Coordinate with Independent Review Organizations and external physician consultants to support appeal decisions.
- Respond to inquiries from regulatory bodies, including Centers for Medicare & Medicaid Services (CMS), as needed.
  
  Qualifications:
  
  Education:
  - High School Diploma or equivalent required
  - BSN or MSN strongly preferred
    
    Experience:
    - Minimum 2 years of direct clinical experience in medical-surgical, acute care, or related setting; or
    - Minimum 3 years of experience in mental health, psychiatric, or behavioral health settings
      
      Preferred Experience:
      - At least 2 years in Utilization Management, Case Management, or Medical Review within a managed care organization or hospital setting
        
        System One, and its subsidiaries including Joulé, ALTA IT Services, and Mountain Ltd., are leaders in delivering outsourced services and workforce solutions across North America. We help clients get work done more efficiently and economically, without compromising quality. System One not only serves as a valued partner for our clients, but we offer eligible employees health and welfare benefits coverage options including medical, dental, vision, spending accounts, life insurance, voluntary plans, as well as participation in a 401(k) plan.
        
        System One is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, age, national origin, disability, family care or medical leave status, genetic information, veteran status, marital status, or any other characteristic protected by applicable federal, state, or local law.
        
        #M2
        
        Ref: #855-IT Baltimore

ALTA IT Services, LLC

Latest Jobs

Clinical Appeals Nurse