Clinical Appeals Nurse

Piper Companies is seeking a Clinical Appeals Nurse to join a leading health insurance organization for a contract remote opportunity located in North Carolina. The Clinical Appeals Nurse will serve as a clinical resource within the appeals team, reviewing complex cases, ensuring regulatory compliance, and supporting accurate benefit determinations. The Clinical Appeals Nurse will work closely with internal stakeholders, providers, and members to facilitate timely appeal resolutions across multiple lines of business.

Responsibilities of the Clinical Appeals Nurse include:

·      Evaluate complex member and provider appeals by reviewing clinical records, policy guidelines, benefit plans, and regulatory requirements to support appeal determinations.

·      Provide clinical guidance and consultation to non-clinical appeals staff throughout the review and resolution process.

·      Obtain and assess medical documentation from providers, legal representatives, pharmaceutical organizations, and other external partners as needed.

·      Present case findings and recommendations to physicians, leadership teams, and review committees while coordinating necessary claim adjustments.

·      Identify appeal trends, compliance concerns, and operational issues, recommending process improvements and educational initiatives to reduce future risk.

Qualifications for the Clinical Appeals Nurse include:

·      Active Registered Nurse (RN) license in the State of North Carolina with at least 3 years of clinical experience.

·      OR active North Carolina licensure as an LPN, Physical Therapist (PT), or Occupational Therapist (OT) with 5+ years of clinical experience.

·      Strong understanding of healthcare appeals, grievance processes, utilization management, and medical necessity reviews.

·      Experience interpreting clinical documentation, insurance benefits, healthcare regulations, and medical policies.

·      Excellent analytical, organizational, communication, and problem-solving skills with the ability to manage multiple priorities.

Compensation for the Clinical Appeals Nurse:

·      Hourly Rate: $25-$35 per hour

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

This job opens for applications on 7/31/26. Applications for this job will be accepted for at least 30 days from the posting date.

Keywords: clinical appeals, appeals nurse, registered nurse, RN, healthcare insurance, utilization management, grievance review, medical necessity, healthcare compliance, managed care, appeals processing, claims review, provider appeals, member appeals, NCQA, healthcare regulations, policy interpretation, clinical documentation review, claims analysis, case management, healthcare operations, regulatory compliance, quality improvement, benefit determinations, medical records review, interdisciplinary collaboration, healthcare administration, patient advocacy, insurance operations, clinical consultation.

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