Appeals Clinician (Monday - Friday)
PacificSource Health Plans(1 month ago)
About this role
The Appeals Clinician represents the clinical component of member and provider appeals for a health plan by summarizing clinical findings and presenting them to medical leadership for final determination. The role involves synthesizing evidence-based information, applicable policies, and claims data to support appeal reviews. This position supports regulatory compliance and collaborates across departments to ensure quality and member-focused outcomes.
Required Skills
- Case Review
- Clinical Review
- Policy Interpretation
- Evidence-Based
- Medical Research
- Claims Analysis
- Stakeholder Collaboration
- Communication
- HIPAA Compliance
- Lean Methodologies
Qualifications
- Registered Nurse (RN) License
- Licensed Behavioral Health Specialist
- Current Unrestricted State License
- State Licensure (OR, MT, ID, WA) may be required
About PacificSource Health Plans
pacificsource.comPacificSource offers health insurance plans for individuals, families, and employers. A Northwest not-for-profit, we put members first.
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