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.

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.

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.

Appeals and Clinical Research RN

Key skills