Clinical Appeals Analyst

Piper Companies is seeking a Clinical Appeals Analyst to join a leading organization in the health‑insurance industry for a fully remote contract position. The Clinical Appeals Analyst will support clinical review activities, coordinate appeals workflows, and ensure compliance with regulatory and medical‑necessity standards.

Responsibilities of the Clinical Appeals Analyst include:

· Conduct clinical reviews for member and provider appeals while ensuring compliance with state, federal, and accreditation requirements.

· Provide clinical consultation to non‑clinical appeals staff and collaborate with physicians and internal leadership.

· Analyze complex documentation, gather required information from external sources, and present case summaries for determination.

· Prepare written case determinations, initiate claim adjustments when necessary, and manage required turnaround times.

· Identify trends, high‑risk issues, and process gaps to recommend internal education or corrective action.

Qualifications for the Clinical Appeals Analyst include:

· Active Registered Nurse license in your state

· Minimum of 3 years of clinical experience for RN applicants.

· Experience with Medicare or Medicare Advantage programs.

· Telephonic appeals, case management, or utilization management experience.

· Strong ability to interpret medical policy, CMS guidelines, and regulatory requirements.

Compensation for the Clinical Appeals Analyst:

· Salary Range: $69,000-$79,000/year (USD)

· Comprehensive Benefits: Medical, Dental, Vision, sick leave if required by law, and 401K

This job opens for applications on 1/29/26. Applications for this job will be accepted for at least 30 days from the posting date.

Keywords: clinical appeals, RN, Medicare, Medicare Advantage, case management, utilization review, medical necessity, clinical documentation, insurance operations, grievance and appeals, CMS, NCQA, telephonic review, healthcare compliance, payer operations.

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