Clinical Appeals RN

About the role

As a Clinical Appeals RN, you play a vital role in ensuring fair, accurate, and timely review of healthcare service and coverage denials. In this position, you will evaluate appeal cases by analyzing medical records and clinical documentation, applying evidence-based guidelines, and determining medical necessity with a balanced, unbiased approach. You will collaborate closely with Medical Directors, Utilization Management, and Case Management teams to support informed decision-making and ensure alignment with organizational policies and regulatory standards. This role is critical in maintaining compliance with state and federal requirements while upholding the integrity of the appeals process. The ideal candidate brings strong clinical expertise, attention to detail, and the ability to manage multiple cases in a fast-paced environment. Your work directly impacts member satisfaction, strengthens stakeholder trust, and contributes to continuous process improvement through trend analysis and insights. Qualifications you'll bring: Active, unrestricted RN license in good standing Graduate of an Accredited nursing program required (BSN preferred) Minimum 3-5 years of clinical nursing experience Strong knowledge of medical terminology, healthcare procedures, and clinical guidelines. Previous experience in clinical appeals, utilization management or managed care and LTSS is highly desirable Ability to interpret clinical documentation and apply evidence-based guidelines Exceptional customer service skills and ability to handle difficult situations with empathy and professionalism Strong attention to detail and ability to manage multiple tasks simultaneously Ability to work independently and as part of a team in a fast-paced environment Your key responsibilities: Evaluate denied service authorizations and claims for medical necessity, appropriateness and compliance with clinical criteria Review and analyze medical records and clinical supporting documentation, making recommendations as to whether the denial should be overturned Collaborate with MVP Medical Directors, Utilization Management and Case Management to ensure alignment with MVP's medical policies Using clinical judgment, present clinical rationale/recommendation to MVP Medical Directors and external consultants for review and determination Ensure compliance with State and Federal regulations, including accreditation requirements (e.g.: CMS, Medicaid, NCQA). Maintain accurate and up-to-date records of appeals, including documentation of all communication in the department's tracking system. Monitor and track status of appeals, ensuring cases are processed within specified timeframes. Identify opportunities for process improvement and contribute to the development and implementation of best practices. Stay updated on changes in regulations and guidelines to ensure compliance and provide accurate information to enrollees. Analyze appeal outcomes to identify trends, patterns, issues with denials, recommending process improvement Where you'll be: Location: hybrid Pay Transparency MVP Health Care is committed to providing competitive employee compensation and benefits packages. The base pay range provided for this role reflects our good faith compensation estimate at the time of posting. MVP adheres to pay transparency nondiscrimination principles. Specific employment offers and associated compensation will be extended individually based on several factors, including but not li

Benefits

Additional Information

Join Us in Shaping the Future of Health Care At MVP Health Care, we're on a mission to create a healthier future for everyone. That means embracing innovation, championing equity, and continuously improving how we serve our communities. Our team is powered by people who are curious, humble, and committed to making a difference-every interaction, every day. We've been putting people first for over 40 years, offering high-quality health plans across New York and Vermont and partnering with forward-thinking organizations to deliver more personalized, equitable, and accessible care. As a not-for-profit, we invest in what matters most: our customers, our communities, and our team.

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