This fully remote role focuses on clinical review of complex appeals and grievances in a health plan setting, with an emphasis on medical necessity, coverage determinations, and regulatory compliance. The clinician reviews documentation, interprets benefit language and clinical guidelines, and supports fair resolution of member and provider cases. The position also serves as a clinical resource for non-clinical staff and helps communicate findings to physician reviewers and review committees.
Key Responsibilities
- Evaluate complex appeal and grievance cases using clinical guidelines, benefit language, regulatory requirements, and coverage policies.
- Gather and review medical records and supporting documentation from providers, legal representatives, and outside organizations.
- Prepare case summaries and recommendations for physician reviewers, leadership, and review committees.
- Serve as a clinical resource for non-clinical team members throughout the appeal review process.
- Respond to member and provider inquiries related to appeals, benefits interpretation, and claims issues.
- Identify process improvement opportunities and support corrective actions for policy application or claims processing concerns.
- Facilitate claim corrections and adjustments as needed to support case resolution.
Required
- Active North Carolina RN license with at least 3 years of clinical experience, or active North Carolina LPN, PT, or OT license with at least 5 years of clinical experience.
- Experience reviewing medical documentation and applying clinical judgment for coverage or reimbursement determinations.
- Strong understanding of healthcare regulations, medical necessity review standards, utilization management, and appeals processes.
- Excellent written and verbal communication skills.
- Ability to manage multiple priorities, work independently, and maintain accuracy in a remote, deadline-driven environment.
Benefits & Perks
- Fully remote work arrangement.
- Long-term contract role.
- Medical, dental, and vision coverage.
- 401(k) eligibility.
- Sick leave if required by law.
- Annual salary range of $70,000 to $80,000.