Appeals Clinician

Work from home within Oregon, Washington, Idaho or Utah Preference will be given to current employees and candidates who reside in Idaho and Utah Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system.

Every day, Cambia’s dedicated team of Appeals Clinicians are living our mission to make health care easier and lives better. As a member of the Clinical Services team, our Appeals Clinician I utilizes clinical expertise to complete the clinical component of all appeal types to resolve member and/or provider appeals – all in service of making our members’ health journeys easier.

What if your clinical expertise could advocate for patients beyond the beside - shaping the outcomes that matter most to them? Are you an RN who finds yourself asking 'why' when a care decision doesn't feel right - and wishing you had the power to change it? Then this role may be the perfect fit.

Bachelor's Degree in Nursing and 3 years of experience in a clinical setting, health insurance, coding/claims review, case management or equivalent combination of education and experience. Active licensure or certification, in a state or territory of the United States, in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline (e.g. medical vs.

behavioral health) and at least 3 years (or full time equivalent) of direct clinical care Registered nurse (RN) license (must have a current unrestricted RN license within either Oregon, Washington, Idaho or Utah).

Demonstrated competency in claim review and experience using billing and claims forms. Proven knowledge of medical and surgical procedures and other healthcare practices. Proven competency to apply clinical expertise to ensure compliance with medical policy. Familiarity regarding rules applied to appeals by accrediting bodies, state and federal governments, and employer groups. Knowledge in reading and interpreting medical records, patient data, and member benefits with an ability to communicate complex topics effectively with clinical and non-clinical staff.

Knowledge of personal computer software, such as Microsoft Word, Excel, PowerPoint and Access. Ability to prepare and present clear and concise written narratives and decisions. Knowledge of CPT, ICD-9 and HCPCS coding and MCG (Milliman Care Guidelines). Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired.

Applies nursing expertise and clinical judgement to ensure written appeal decisions are in compliance with medical policy, medical necessity guidelines, reimbursement policies, federal regulation, company policy, industry standard and accepted standards of care. Conducts clinical appeal reviews which adhere to member benefits and provider and hospital contracts. Consults with physician advisers to ensure clinically appropriate determinations when required. Advises and educates non-clinical appeals staff on clinical cases.

#LI-Remote Pay ranges vary based on the candidate's work location. The expected hiring range depends on skills, experience, education, and training; relevant licensure / certifications; and performance history. Oregon, Washington, Utah, and Idaho:
The expected hiring range is $36.80 - $49.80, the full salary range is $34.60 - $56.30 and the bonus target is 8%.

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues…