Appeals Clinician I

Job not on LinkedIn

🔥 1 minute ago

🥔 Idaho, Oregon, +2 more states – Remote

🥔 Idaho – Remote 🌲 Oregon – Remote ⛷️ Utah – Remote ☕ Washington – Remote

💵 $34 - $56 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Cambia Health Solutions

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

🏥 Healthcare

⚕️ Healthcare Insurance

🤝 Non-profit

Healthcare • Healthcare Insurance • Non-profit

Cambia Health Solutions is a nonprofit, mission-driven healthcare company based in Portland, Oregon, that operates consumer-focused health care and health insurance businesses and invests in health innovation. It serves as the parent organization for the Regence family of health plans and runs initiatives and subsidiaries focused on improving care delivery, providing insurance products, and developing digital health tools and services.

📋 Description

• Complete the clinical component of all appeal types to resolve member and/or provider appeals • Apply nursing expertise and clinical judgment to ensure written appeal decisions comply with medical policy, medical necessity guidelines, reimbursement policies, federal regulations, company policy, industry standards and accepted standards of care • Conduct clinical appeal reviews adhering to member benefits and provider and hospital contracts • Consult with physician advisers to ensure clinically appropriate determinations when required • Advise and educate non-clinical appeals staff on clinical cases

🎯 Requirements

• 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 allowing independent assessment within scope of practice • At least 3 years (or full-time equivalent) of direct clinical care • Current unrestricted Registered Nurse (RN) license within Oregon, Washington, Idaho or Utah • Demonstrated competency in claim review and experience using billing and claims forms • Knowledge of medical and surgical procedures and healthcare practices • Competency applying clinical expertise to ensure compliance with medical policy • Familiarity with appeals rules applied by accrediting bodies, state and federal governments, and employer groups • Ability to read and interpret medical records, patient data and member benefits • Ability to communicate complex topics effectively with clinical and non-clinical staff • Knowledge of Microsoft Word, Excel, PowerPoint and Access • Ability to prepare and present clear, concise written narratives and decisions • Knowledge of CPT, ICD-9, HCPCS coding and MCG (Milliman Care Guidelines) • Experience with AI tools and technologies highly desired • Wired internet connection required; minimum 5 Mb upload and 10 Mb download speed; satellite or cellular connections not accepted • Personal mobile device required for Multi-Factor Authentication • Background check required

🏖️ Benefits

• Competitive salary • Bonus opportunities • Market-leading 401(k) with a significant company match • Potential discretionary 401(k) contribution based on company performance with no vesting period • Medical, dental and vision coverage for employees and eligible family members, including mental health benefits • Annual employer contribution to a health savings account • Generous paid time off • 10 company-paid holidays • Up to 12 weeks of paid parental time off, subject to eligibility • Award-winning wellness programs that reward participation • Employee Assistance Fund • Commute and parking benefits • Work from home options for most roles • Employee resource groups • Cambia-supported outreach programs • Career growth and professional development opportunities