AMVETS Jobs

Appeals Clinician I Work from home within Oregon, Washington, Idaho or Utah Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system. Who We Are Looking For: Every day, Cambia's dedicated team of Appeals Clinicians are living our mission to make health care easier and lives better. As a member of the Health Services Organization team, our Appeals Clinicians utilize clinical expertise to complete the clinical component of all appeal types to resolve member and/or provider appeals - all in service of making our members' health journeys easier. Are you passionate about being a voice for patients in complex healthcare situations? Do you want to utilize your clinical expertise in a way that impacts thousands of lives? Then this role may be the perfect fit. What You Bring to Cambia: Qualifications: * Bachelor's Degree in Nursing * 3 years of experience in a clinical setting, health insurance, coding/claims review, case management * Equivalent combination of education and experience * Must have licensure or certification, in a state or territory of the United States, in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline (e.g. medical vs. behavioral health) and at least 3 years (or full time equivalent) of direct clinical care * Bachelor's degree (or higher) in a health or human services-related field (psychiatric RN or Masters degree in Behavioral Health preferred for behavioral health appeals management); or * Registered nurse (RN) license (must have a current unrestricted RN license within either OR, WA, ID or UT) Skills and Attributes: * Demonstrated competency in claim review and experience using billing and claims forms. * Proven knowledge of medical and surgical procedures and other healthcare practices. * Proven competency to apply clinical expertise to ensure compliance with medical policy. * Familiarity regarding rules applied to appeals by accrediting bodies, state and federal governments, and employer groups. * Knowledge in reading and interpreting medical records, patient data, and member benefits with an ability to communicate complex topics effectively with clinical and non-clinical staff. * Knowledge of personal computer software, such as Microsoft Word, Excel, PowerPoint and Access. * Ability to prepare and present clear and concise written narratives and decisions. * Knowledge of CPT, ICD-9 and HCPCS coding and MCG (Milliman Care Guidelines). * Ability to work overtime (more details to come during interview). What You Will Do at Cambia: * Applies nursing expertise and clinical judgement to ensure written appeal decisions are in compliance with medical policy, medical necessity guidelines, reimbursement policies, federal regulation, company policy, industry standard and accepted standards of care. * Conducts clinical appeal reviews which adhere to member benefits and provider and hospital contracts. * Consults with physician advisers to ensure clinically appropriate determinations when required. * Advises and educates non-clinical appeals staff on clinical cases. #LI-Remote The expected hiring range for an Appeals Clinician is $36.40 - $49.20 an hour depending on skills, experience, education, and training; relevant licensure / certifications; and performance history. The bonus target for this position is 10%. The current full salary range for this role is $34.20 - $55.70 an hour. About Cambia Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Ou To view the full job description,