Appeals and Clinical Research RN
Job Description:
• Reviews and makes appropriate appeal determinations according to applicable appeal policies and procedures, medical policies, reimbursement policies, and coding policies.
• Handles emergent and standard appeal requests and makes appropriate determinations using medical knowledge, judgement, expertise, and interpretation of medical policy and standards of practice.
• Prepares cases for review by the Medical Director so a final determination can be made.
• Ensures providers and members are notified on all emergent case types.
• Identifies patterns and practices within the organization.
• Assists in analyzing and reporting of appeals data.
• Provides education on appeals processes to areas of the organization as appropriate.
• Reviews existing medical policies and develops new policies in collaboration with Medical Directors and Medical Policy Leadership.
• Identifies trends that may need to be addressed in policy and works collaboratively with leadership to incorporate them as appropriate.
• Assists with appropriate research needed including regulatory standards, standards of practice, utilization studies, plan surveys, literature research, and consultants.
• Serves as a clinical point of contact for the organization for numerous internal parties.
• Participates in various projects and workgroups within the organization.
• Researches complex clinical issues and internal resources including benefit matrix, benefit plans, policies, and external sources which may impact claims.
Requirements:
• Associate's degree and completion of RN program. BSN is preferred.
• 3+ years in appeals/clinical research, health insurance utilization/medical review, or related experience.
• North Dakota (ND) Registered Nurse (RN) License or RN License valid for work in ND.
• Demonstrated nursing expertise with the ability to apply clinical knowledge to complex medical reviews, appeals, and policy interpretation.
• Strong verbal and written communication skills, with the ability to clearly articulate clinical rationale to internal teams, providers, and leadership.
• Sound decision‑making ability, including exercising professional judgment when interpreting medical policy, standards of practice, and clinical information.
• Proven analytical thinking skills to evaluate complex clinical scenarios, identify patterns, and support accurate and consistent determinations.
• Ability to conduct research and data analysis using clinical literature, medical policies, regulatory guidance, and internal resources to support decisions.
• Strong prioritization and organizational skills, with the ability to manage multiple cases, meet deadlines, and adapt to shifting priorities in a fast‑paced environment.
• Equivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standards.
Benefits:
• Affordable medical, dental and vision coverage accepted throughout the United States
• Employer funded Lifestyle Spending Accounts and Health Savings Accounts.
• Voluntary employee contributions to Health Savings Accounts and Flexible Spending Accounts
• Employer-paid life and disability insurance
• 401(k) retirement plan with company match and immediate vesting
• Paid holidays, paid time off (PTO), PTO donation program, and paid parental leave
• Voluntary benefits including Accident, Hospital Indemnity, Critical Illness, Term/Whole Life, Cancer Care Insurance, and more.
• Additional company perks
• Robust mental health offerings including an Employee Assistance Program, Learn to Live, meQ.
• Comprehensive learning and development opportunities and an Educational Assistance Program.
• 16 hours of paid volunteer time with a $200 donation to a charity of your choice upon completion of all volunteer hours.
• Employee recognition, community initiative events and yearly company outings.
• Workplace flexibility offering different options for working arrangements and the freedom to make time for important commitments.
• Opportunities to connect through employee committees.
• Reviews and makes appropriate appeal determinations according to applicable appeal policies and procedures, medical policies, reimbursement policies, and coding policies.
• Handles emergent and standard appeal requests and makes appropriate determinations using medical knowledge, judgement, expertise, and interpretation of medical policy and standards of practice.
• Prepares cases for review by the Medical Director so a final determination can be made.
• Ensures providers and members are notified on all emergent case types.
• Identifies patterns and practices within the organization.
• Assists in analyzing and reporting of appeals data.
• Provides education on appeals processes to areas of the organization as appropriate.
• Reviews existing medical policies and develops new policies in collaboration with Medical Directors and Medical Policy Leadership.
• Identifies trends that may need to be addressed in policy and works collaboratively with leadership to incorporate them as appropriate.
• Assists with appropriate research needed including regulatory standards, standards of practice, utilization studies, plan surveys, literature research, and consultants.
• Serves as a clinical point of contact for the organization for numerous internal parties.
• Participates in various projects and workgroups within the organization.
• Researches complex clinical issues and internal resources including benefit matrix, benefit plans, policies, and external sources which may impact claims.
Requirements:
• Associate's degree and completion of RN program. BSN is preferred.
• 3+ years in appeals/clinical research, health insurance utilization/medical review, or related experience.
• North Dakota (ND) Registered Nurse (RN) License or RN License valid for work in ND.
• Demonstrated nursing expertise with the ability to apply clinical knowledge to complex medical reviews, appeals, and policy interpretation.
• Strong verbal and written communication skills, with the ability to clearly articulate clinical rationale to internal teams, providers, and leadership.
• Sound decision‑making ability, including exercising professional judgment when interpreting medical policy, standards of practice, and clinical information.
• Proven analytical thinking skills to evaluate complex clinical scenarios, identify patterns, and support accurate and consistent determinations.
• Ability to conduct research and data analysis using clinical literature, medical policies, regulatory guidance, and internal resources to support decisions.
• Strong prioritization and organizational skills, with the ability to manage multiple cases, meet deadlines, and adapt to shifting priorities in a fast‑paced environment.
• Equivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standards.
Benefits:
• Affordable medical, dental and vision coverage accepted throughout the United States
• Employer funded Lifestyle Spending Accounts and Health Savings Accounts.
• Voluntary employee contributions to Health Savings Accounts and Flexible Spending Accounts
• Employer-paid life and disability insurance
• 401(k) retirement plan with company match and immediate vesting
• Paid holidays, paid time off (PTO), PTO donation program, and paid parental leave
• Voluntary benefits including Accident, Hospital Indemnity, Critical Illness, Term/Whole Life, Cancer Care Insurance, and more.
• Additional company perks
• Robust mental health offerings including an Employee Assistance Program, Learn to Live, meQ.
• Comprehensive learning and development opportunities and an Educational Assistance Program.
• 16 hours of paid volunteer time with a $200 donation to a charity of your choice upon completion of all volunteer hours.
• Employee recognition, community initiative events and yearly company outings.
• Workplace flexibility offering different options for working arrangements and the freedom to make time for important commitments.
• Opportunities to connect through employee committees.