Medical Review Nurse - Risk & Appeals

About the role

Are you a clinically experienced Registered Nurse looking to apply your expertise beyond direct patient care? As a Medical Review Nurse you will play a critical role in strengthening risk management and improving decision-making across our health and accident products. You'll use your clinical knowledge to evaluate medical records, guide coverage determinations, and support fair, evidence-based appeal outcomes-directly impacting both business outcomes and member experience. This is an opportunity to bring your clinical judgment, analytical thinking, and passion for quality care into a dynamic, fast-paced environment where your insights drive meaningful results.

Responsibilities

• Serve as a trusted clinical expert supporting accident and health lines of business
• Review medical records and claims to determine coverage and benefit eligibility
• Evaluate medical necessity and appropriateness of care based on evidence-based guidelines
• Draft clear, defensible written rationales for coverage and appeal determinations
• Analyze medical and claims data to identify trends, risks, and improvement opportunities
• Assess medical information to determine current and potential risk exposure for coverage decisions
• Interpret and apply policy contract language to ensure consistent, accurate determinations
• Synthesize complex data from multiple sources to inform business decisions
• Maintain strong productivity and quality in a high-volume, fast-paced environment
• Collaborate cross-functionally while demonstrating strong independence and accountability
• What You Bring
• Required
• Active Registered Nurse (RN) license
• Proven ability to analyze and interpret complex medical information and documentation
• Strong clinical judgment and decision-making skills
• Excellent written and verbal communication skills
• Preferred
• 5+ years of clinical nursing experience
• Experience in health insurance, utilization review, medical claims, or appeals
• Familiarity with medical coding systems (CPT, ICD-10, HCPCS) and claims documentation
• Experience interpreting insurance policy language and applying it in decision-making
• Exposure to data analysis and identifying trends within medical or claims data
• Key Skills & Strengths
• Analytical mindset with strong attention to detail
• Ability to translate clinical complexity into clear, actionable insights
• Strong problem-solving and critical thinking capabilities
• Effective time management and ability to prioritize competing demands
• Comfortable working both independently and collaboratively
• Tools & Expertise
• Proficiency in Microsoft Office (Excel, Word, Outlook)
• Experience working with medical records, physician notes, and evidence-based clinical studies
• Ability to interpret Explanation of Benefits (EOBs) and submitted claims
• Why Join Us
• Impact: Your clinical expertise directly influences fair, data-driven decisions that affect members and the business
• Growth: Expand your career beyond bedside care into analytics, risk management, and insurance
• Flexibility: Work in a collaborative, fast-paced corporate environment with opportunities to deepen your expertise
• Purpose: Help ensure accurate, evidence-based decisions that support better outcomes

Requirements

• Clinical Experience, Clinical Knowledge, Communication, Critical Thinking, Decision Making, Problem Solving

Benefits

Additional Information

At Allstate, great things happen when our people work together to protect families and their belongings from life's uncertainties. And for more than 90 years, our innovative drive has kept us a step ahead of our customers' evolving needs. From advocating for seat belts, air bags and graduated driving laws, to being an industry leader in pricing sophistication, telematics, and, more recently, device and identity protection. Job Description

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