Clinical - Appeals Nurse

Job Summary Position Purpose: Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met Education/Experience: LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. Proficient with Microsoft Office applications. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred. License/Certification: RN or LPN license. For Fidelis Care only: NYS RN license required. Responsibilities • Review clinical data to determine claim payment based on company policies and • National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review • Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received • Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions • Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution • Gather and prepare case information for Administrative Law Hearings • Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database • Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements. EEO: "Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of - Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans." Position Purpose: Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met Education/Experience: LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. Proficient with Microsoft Office applications. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred. License/Certification: RN or LPN license. Responsibilities • Review clinical data to determine claim payment based on company policies and • National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review • Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received • Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions • Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution • Gather and prepare case information for Administrative Law Hearings • Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database • Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements. Story Behind the Need - Business Group & Key Projects Health plan or business unit Team culture Surrounding team & key projects Purpose of this team Reason for the request Motivators for this need ny additional upcoming hiring needs? The Clinical Appeals team plays a vital role in supporting Absolute Total Care's regulatory compliance, operational integrity, and member and provider experience. The team is responsible for timely and accurate review of provider disputes, member grievances, and appeals, with a strong focus on meeting State and NCQA requirements. The team operates within a highly collaborative and motivated culture. Currently staffed with three experienced employees in equivalent roles, the group works closely together to field questions, share clinical expertise, and maintain high performance standards. Additional support is needed to maintain continuity, protect compliance standards, and sustain team performance during this time of decreased staffing. Typical Day in the Role Daily schedule & OT expectations Typical task breakdown and rhythm Interaction level with team Work environment description Review clinical appeals Prepare clinical reviews for cases that do not meet established criteria. Gather, analyze, and document verbal and written information related to member and provider appeals. Draft and finalize appeal response letters ensuring compliance with State and NCQA requirements. Maintain accurate appeal files, logs, and documentation for audit readiness. Collaborate with Medical Directors to clarify clinical rationale and medical determinations. Coordinate fair hearings with internal departments and external agencies. Compelling Story & Candidate Value Proposition What makes this role interesting? Points about team culture Competitive market comparison Unique selling points Value added or experience gained Candidates for this role will help ensure decisions are clinically sound, clearly communicated, and compliant, while protecting timeliness standards that matter to members and providers. Which means they sit at the intersection of clinical judgment, member advocacy, and regulatory excellence. Team members are readily available to answer questions and keep each other motivated with the concept that we are "Stronger Together". We offer the best of both worlds-stability and team connection plus high-impact and skill-building work. Overall, our employees gain a highly marketable blend of skills that opens doors across UM, quality, compliance, and leadership tracks.

Created: 2026-03-10