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Clinical Appeal Auditor Jobs (NOW HIRING)

Solis Health Plans

NY · On-site

$60 - $80/hr

The auditor evaluates case accuracy, procedural compliance, clinical and coverage determinations ... Assess adherence to CMS requirements for notices, including denial letters, appeal determinations ...

Solis Health Plans, Inc.

NY · On-site

$60 - $80/hr

The auditor evaluates case accuracy, procedural compliance, clinical and coverage determinations ... Assess adherence to CMS requirements for notices, including denial letters, appeal determinations ...

Solis Health Plans, Inc.

$60 - $80/hr

The auditor evaluates case accuracy, procedural compliance, clinical and coverage determinations ... Assess adherence to CMS requirements for notices, including denial letters, appeal determinations ...

New

Solis Health Plans

Grievance & Appeals Auditor I

Doral, FL · On-site

$55K - $65K/yr

The auditor evaluates case accuracy, procedural compliance, clinical and coverage determinations ... Assess adherence to CMS requirements for notices, including denial letters, appeal determinations ...

WVU Medicine

Clinical Denials Specialist

This includes but is not limited to, denial investigation, follow-up with insurance companies, billing, auditors and clinics/hospital departments, non-clinical appeal writing, accurate and timely ...

WVU Medicine

Clinical Denials Coord

Morgantown, WV · On-site

Coordinates all referrals for further appeal to outside agencies based on department guidelines ... auditors regarding billing issues as needed to reach agreement on disputed items; provides ...

WVU Medicine

Clinical Denials Coord

Morgantown, WV · On-site

Coordinates all referrals for further appeal to outside agencies based on department guidelines ... auditors regarding billing issues as needed to reach agreement on disputed items; provides ...

Independence Blue Cross

Supervisor Appeals

Philadelphia, PA · On-site

$22.25 - $27.50/hr

... clinical)appeals. This role ensures timely, accurate, and compliant processing of member and ... Compliance, Auditing & Quality Assurance * Conducts regular audits of closed appeals files to ...

West Virginia University Health System

Coordinates all referrals for further appeal to outside agencies based on department guidelines ... auditors regarding billing issues as needed to reach agreement on disputed items; provides ...

Elevance Health

DRG Clinical Auditor Principal

Mason, OH

$122K - $183K/yr

DRG Clinical Auditor Principal Location: This role enables associates to work virtually full-time, ... or appeals may only be reviewed by other DRG Coding Audit Principals (or Executives). How you'll ...

Phelps Health

Nurse Auditor Reviewer

This position supports the Denial, Prevention, and Recovery Department (DPR) by providing Clinical Data Analyst and Review services. The Nurse Auditor performs appeal writing, reviews, and other ...

Phelps Health

Nurse Auditor Reviewer

This position supports the Denial, Prevention, and Recovery Department (DPR) by providing Clinical Data Analyst and Review services. The Nurse Auditor performs appeal writing, reviews, and other ...

Phelps Health

Nurse Auditor Reviewer

Phelps, NY · Hybrid

This position supports the Denial, Prevention, and Recovery Department (DPR) by providing Clinical Data Analyst and Review services. The Nurse Auditor performs appeal writing, reviews, and other ...

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Clinical Appeal Auditor information

See salary details

$38.5K

$92.8K

$151K

How much do clinical appeal auditor jobs pay per year?

As of Sep 9, 2026, the average yearly pay for clinical appeal auditor in the United States is $92,797.00, according to ZipRecruiter salary data. Most workers in this role earn between $72,000.00 and $112,000.00 per year, depending on experience, location, and employer.

What is a clinical appeal auditor?

Clinical Appeal Auditors are healthcare professionals who review denied insurance claims to determine if clinical documentation supports the necessity and appropriateness of the care provided. They analyze medical records, insurance policies, and relevant regulations to prepare appeals for overturned denials. Their role is crucial in helping healthcare providers and patients receive appropriate reimbursement and coverage for medical services. Clinical Appeal Auditors often work for hospitals, insurance companies, or third-party organizations and need a strong background in healthcare, coding, and regulatory compliance.

How does a clinical appeal auditor typically collaborate with other departments in the healthcare organization?

Clinical Appeal Auditors frequently work alongside medical coding teams, clinicians, and legal or compliance departments to review and resolve denied insurance claims. Collaboration is essential to gather detailed clinical information, interpret medical records, and ensure that appeals are well-supported by documentation and regulatory guidelines. Regular interaction with these teams helps streamline the appeals process and ensures that all necessary evidence is considered, making effective communication skills a key aspect of the role.

What are the key skills and qualifications needed to thrive as a clinical appeal auditor, and why are they important?

To thrive as a Clinical Appeal Auditor, you need in-depth knowledge of medical coding, clinical documentation, and healthcare regulations, often supported by credentials such as RN, RHIA, or CCS. Familiarity with electronic health records (EHRs), claims management systems, and auditing tools is typically required. Strong analytical thinking, attention to detail, and effective written communication are vital soft skills for reviewing complex cases and creating persuasive appeals. These competencies ensure accurate claim evaluations, regulatory compliance, and successful resolution of denied claims.

What is the difference between Clinical Appeal Auditor vs Claims Reviewer?

AspectClinical Appeal AuditorClaims Reviewer
Required CredentialsHealthcare certifications, clinical knowledgeInsurance or claims processing certifications
Work EnvironmentHealthcare facilities, insurance companiesInsurance companies, healthcare payers
Industry UsageHealthcare, insuranceInsurance, healthcare reimbursement
Primary FocusReviewing denied appeals based on clinical criteriaEvaluating claims for accuracy and compliance

While both roles involve reviewing healthcare-related cases, a Clinical Appeal Auditor focuses on analyzing denied claims based on clinical standards, whereas a Claims Reviewer assesses claims for accuracy and policy compliance. Understanding these differences helps in choosing the right career path or job search focus within healthcare and insurance industries.

What cities are hiring for Clinical Appeal Auditor jobs?

Cities with the most Clinical Appeal Auditor job openings:

What are popular job titles related to Clinical Appeal Auditor jobs?

For Clinical Appeal Auditor jobs, the most frequently searched job titles are:

Infographic showing various Clinical Appeal Auditor job openings in the United States as of August 2026, with employment types broken down into 3% As Needed, 71% Full Time, 18% Part Time, and 8% Contract. Highlights an 95% Physical, 1% Hybrid, and 4% Remote job distribution, with an average salary of $92,797 per year, or $44.6 per hour.

Grievance & Appeals Auditor I

NY • On-site

Solis Health Plans
Insurance Services • 11 - 50 employees
Learn more about Solis Health Plansexternal

$60 - $80/hr

Other

Posted 4 days ago

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Grievance & Appeals Auditor I

Doral, FL, US

Salary Range: $55,000.00 To $65,000.00 Annually

Job Summary

The Grievance and Appeals (G&A) Auditor is responsible for performing end-to-end audit of appeals and grievance cases . T his role ensures compliance with applicable regulatory requirements, including standards established by the Centers for Medicare & Medicaid Services (CMS). The auditor evaluates case accuracy, procedural compliance, clinical and coverage determinations, and timeliness standards, while identifying opportunities for process improvement and risk mitigation.

Key Responsibilities

Primary duties may include, but are not limited to:

  • Conduct pre- and post-resolution audits of member appeals and grievance cases across Medicare Advantage and other managed care lines of business.
  • Ensure compliance with CMS Medicare Advantage Appeals and Grievance regulations, internal policies, and regulatory timeframes.
  • Review case files for accuracy and completeness, including:
  • Member eligibility and benefit coverage
  • Medical necessity determinations
  • Clinical rationale and supporting documentation
  • Benefit interpretation and plan policy application
  • Provider and member communications
  • Validate that appropriate clinical and administrative review levels were applied throughout the appeals and grievance lifecycle.
  • Assess adherence to CMS requirements for notices, including denial letters, appeal determinations, and grievance responses.

Audit & Compliance Oversight

  • Identify procedural errors, compliance gaps, and documentation deficiencies.
  • Evaluate timeliness of case resolution against regulatory standards.
  • Document audit findings with clear rationale, regulatory citations, and impact assessments.
  • Support audit readiness and regulatory examination activities.

Documentation & Reporting

  • Prepare detailed audit reports outlining:
  • Case review findings and decision accuracy
  • Procedural and compliance deviations
  • Financial, operational, or regulatory risk exposure
  • Track audit outcomes to identify trends in appeals and grievance processing errors.
  • Support reporting for compliance committees, regulatory audits, and internal quality initiatives.

Quality Improvement & Support

  • Provide feedback to Grievance and Appeals teams regarding identified errors and improvement opportunities.
  • Recommend corrective actions, training needs, and process enhancements.
  • Identify systemic issues and collaborate with leadership, compliance, and operational teams to implement solutions.
  • Escalate potential compliance risks or regulatory violations as appropriate.
  • Partner with clinical reviewers, compliance officers, and operational leaders to resolve complex case issues.
  • Communicate audit findings clearly to both technical and non-technical stakeholders.
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