Select Source International · 16 hours ago
Clinical Appeals Case Manager (RN Health Plans)
United States
Full-time
Remote
Mid Level
3+ years expSelect Source International (SSI) is a distinguished staffing company with nearly 25 years of experience, renowned for delivering top-tier workforce solutions. The Clinical Appeals Case Manager conducts clinical reviews of member and provider appeals, ensuring compliance with medical necessity criteria and regulatory requirements while providing clinical consultation and coordinating workflows.
ConsultingFinancial ServicesInformation Technology
Responsibilities
Analyze complex and non-routine appeals and grievances across multiple lines of business
Apply Corporate Medical Policy, contract provisions, Medicare/Medicare Advantage rules, and NCQA standards
Coordinate all aspects of the appeals process to meet regulatory and turnaround requirements
Support Level 3 appeals and physician committee reviews as required
Identify and obtain required documentation from external entities (providers, attorneys, pharmaceutical companies)
Present clinical analysis and recommendations to physician committees and leadership
Initiate claim adjustments when appropriate
Prepare and issue written appeal determinations in compliance with legislative mandates
Identify trends, high-risk issues, and noncompliance drivers; recommend corrective actions
Develop action plans to address benefit misinterpretation or system errors
Respond to member and provider inquiries via inbound calls
Coordinate with external vendors and regulatory stakeholders
Qualification
Required
Active Registered Nurse license in the state of North Carolina
OR LPN, PT, or OT licensed in North Carolina with 5+ years of clinical experience
Minimum 3–5 years of relevant clinical experience
Strong knowledge of clinical coverage criteria and medical necessity review
Experience with Medicare or Medicare Advantage populations
Company
Select Source International
Select Source International (SSI) is an award-winning global leader in Consulting and Staff Augmentation, helping businesses thrive across IT, Healthcare, Finance & Accounting, Human Resources, Engineering, Energy & Utilities, Manufacturing, Administrative, Operations & Logistics, and more.
501-1000 employees
Funding
Current Stage
Late StageCompany data provided by crunchbase