Clinical Appeals Nurse

Job Description

Salary - (60k - 68k depending on experience)

The Clinical Appeals Nurse is responsible for managing clinical appeals and state hearings across all states. This role involves reviewing and completing both provider and member clinical appeals within designated timeframes, preparing State Hearing packets, and ensuring communication with state agencies and internal departments. The successful candidate will attend State Hearings, issue notification letters, refer medical necessity denials, and maintain accurate documentation. Additionally, this role requires collaboration with the Quality Improvement and Clinical Operations Team to manage requests for Independent External Review and ensure compliance with regulatory standards.

Work Environment

Fully remote role. Consultants will need to provide their own equipment including phone, internet, computer, and monitors.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

Diversity, Equity & Inclusion

At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:

• Hiring diverse talent
• Maintaining an inclusive environment through persistent self-reflection
• Building a culture of care, engagement, and recognition with clear outcomes
• Ensuring growth opportunities for our people