Appeals Clinician I

Cambia Health Solutions • Beaverton, OR

10d • $72,000 - $117,000 • Remote

About The Position

Appeals Clinician I Work from home within Oregon, Washington, Idaho or Utah Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system. Who We Are Looking For: 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.

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 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).

Nice To Haves

• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired

Responsibilities

• 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.

Benefits

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
• Award-winning wellness programs that reward you for participation.
• Employee Assistance Fund for those in need.
• Commute and parking benefits.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level