Medical Review Nurse – Risk & Appeals

Allstate • Milwaukee, WI

5d • $62,100 - $103,950 • Hybrid

About The Position

As a Medical Review Nurse, you will play a critical role in strengthening risk management and improving decision-making across Allstate's health and accident products. You’ll use your clinical knowledge to evaluate medical records, guide coverage determinations, and support fair, evidence-based appeal outcomes—directly impacting both business outcomes and member experience. This is an opportunity to bring your clinical judgment, analytical thinking, and passion for quality care into a dynamic, fast-paced environment where your insights drive meaningful results.

Requirements

• Active Registered Nurse (RN) license
• Proven ability to analyze and interpret complex medical information and documentation
• Strong clinical judgment and decision-making skills
• Excellent written and verbal communication skills
• Proficiency in Microsoft Office (Excel, Word, Outlook)
• Experience working with medical records, physician notes, and evidence-based clinical studies
• Ability to interpret Explanation of Benefits (EOBs) and submitted claims

Nice To Haves

• 5+ years of clinical nursing experience
• Experience in health insurance, utilization review, medical claims, or appeals
• Familiarity with medical coding systems (CPT, ICD-10, HCPCS) and claims documentation
• Experience interpreting insurance policy language and applying it in decision-making
• Exposure to data analysis and identifying trends within medical or claims data

Responsibilities

• Serve as a trusted clinical expert supporting accident and health lines of business
• Review medical records and claims to determine coverage and benefit eligibility
• Evaluate medical necessity and appropriateness of care based on evidence-based guidelines
• Draft clear, defensible written rationales for coverage and appeal determinations
• Analyze medical and claims data to identify trends, risks, and improvement opportunities
• Assess medical information to determine current and potential risk exposure for coverage decisions
• Interpret and apply policy contract language to ensure consistent, accurate determinations
• Synthesize complex data from multiple sources to inform business decisions
• Maintain strong productivity and quality in a high-volume, fast-paced environment
• Collaborate cross-functionally while demonstrating strong independence and accountability

Benefits

• Comprehensive technology setup, including a laptop, monitors, headset, keyboard, and mouse
• Monthly connectivity reimbursement for eligible remote employees
• Opportunity to expand career beyond bedside care into analytics, risk management, and insurance

What This Job Offers

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