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Clinical Appeals Jobs (NOW HIRING)

Independence Blue Cross

Clinical Appeals Coord

$22.50 - $28/hr

Position Summary The Clinical Appeals Coordinator, RN is responsible for supporting the end-to-end processing of clinical appeals, including medical necessity, benefit, pharmacy, behavioral health ...

Ageatia Global Solutions

Nurse, Clinical Appeals

Clinical Appeals Nurse We are seeking an experienced Clinical Appeals Nurse to support the appeal and grievance processes by analyzing and responding to adverse coverage decisions. This role involves ...

Ageatia Global Solutions

Clinical Appeals Nurse

Clinical Appeals Specialist The Clinical Appeals Specialist completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The ...

MedReview

Appeals Specialist

Manhattan, NY · On-site +1

$50K/yr

Position Summary At MedReview, our mission is to bring accuracy, accountability, and clinical ... The Appeals Specialist I is responsible for performing triage, review, analysis, and resolution of ...

MedReview

Appeals Specialist

Manhattan, NY · Remote

Position Summary At MedReview, our mission is to bring accuracy, accountability, and clinical ... The Appeals Specialist I is responsible for performing triage, review, analysis, and resolution of ...

Netsmart

Clinical Appeals Nurse - PRN

Prepare and submit clinical appeals in response to denials from managed care organizations, governmental entities, and Recovery Audit Contractors (RACs) for hospital clients * Review medical records ...

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Clinical Appeals information

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$30K

$69.5K

$121K

How much do clinical appeals jobs pay per year?

As of Aug 11, 2026, the average yearly pay for clinical appeals in the United States is $69,454.00, according to ZipRecruiter salary data. Most workers in this role earn between $45,000.00 and $83,000.00 per year, depending on experience, location, and employer.

What are the key skills and qualifications needed to thrive as a clinical appeals specialist?

To thrive as a Clinical Appeals Specialist, you need a solid understanding of medical terminology, insurance guidelines, and healthcare regulations, typically supported by a degree in healthcare or nursing and relevant experience. Familiarity with claims management software, electronic health records (EHRs), and appeals processing systems is essential. Strong attention to detail, analytical thinking, and effective written and verbal communication skills help set top performers apart. These abilities are crucial for successfully navigating complex appeals processes, ensuring accurate documentation, and achieving favorable outcomes for patients and healthcare providers.

What are clinical appeals?

Clinical appeals are the formal process by which healthcare providers, patients, or their representatives challenge a health insurance company's denial or limitation of coverage for medical services. The process involves submitting documentation and clinical evidence to support the necessity of the treatment or service in question. Clinical appeals specialists review medical records, insurance policies, and clinical guidelines to craft persuasive arguments that demonstrate why the denied service should be approved. This role is essential in ensuring patients receive the care they need and that providers are reimbursed appropriately. Effective clinical appeals can impact patient outcomes and the financial health of healthcare organizations.

What is the difference between Clinical Appeals vs Medical Claims Reviewer?

AspectClinical AppealsMedical Claims Reviewer
Required CredentialsMedical degree or clinical certification, knowledge of healthcare regulationsBackground in healthcare, insurance, or billing; often requires coding certifications
Work EnvironmentHealthcare facilities, insurance companies, or third-party administratorsInsurance companies, healthcare payers, or billing departments
Primary ResponsibilitiesReview and contest denied clinical or medical necessity decisionsExamine and process insurance claims for accuracy and compliance

Clinical Appeals specialists focus on challenging denied claims based on medical necessity, requiring clinical knowledge and certifications. Medical Claims Reviewers primarily verify claim accuracy and compliance, often with billing or coding expertise. Both roles are essential in healthcare reimbursement but differ in their focus and required credentials.

What are some typical challenges faced by professionals working in clinical appeals, and how can these be managed effectively?

Professionals in Clinical Appeals often encounter challenges such as navigating complex medical policies, tight turnaround times for appeals, and communicating effectively with both healthcare providers and insurance payers. Managing these challenges requires strong organizational skills, attention to detail, and a deep understanding of medical terminology and insurance regulations. Building effective collaboration with clinical staff, staying current with the latest policy updates, and utilizing available technology for documentation and tracking can help streamline the appeals process and improve outcomes.
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What cities are hiring for Clinical Appeals jobs? Cities with the most Clinical Appeals job openings:
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Clinical Appeals jobs near you
Infographic showing various Clinical Appeals job openings in the United States as of August 2026, with employment types broken down into 100% Full Time. Highlights an 50% In-person, and 50% Remote job distribution, with an average salary of $69,454 per year, or $33.4 per hour.

Clinical Appeals Specialist

Independent Living Systems

Miami, FL • On-site

Full-time

Posted 8 days ago

Independent Living Systems rating

6.5

Company rating: 6.5 out of 10

Based on 9 frontline employees who took The Breakroom Quiz

Job description

We are seeking a Clinical Appeals Specialist to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations.

About the Role:

The Clinical Appeals Specialist plays an essential role managing and resolving clinical appeals related to insurance claims and member care. The Clinical Appeals Specialist ensures that appeals are thoroughly reviewed, accurately documented, and effectively communicated to insurance providers, healthcare professionals, and members. The Clinical Appeals Specialist collaborates closely with clinical teams to gather necessary medical information and supports the appeals process by interpreting clinical guidelines and insurance policies. The goal is to facilitate timely outcomes that uphold member rights and optimize reimbursement for healthcare services. The Clinical Appeals Specialist requires a detail-oriented professional who can navigate complex regulatory environments while maintaining a member-centered approach.

Minimum Qualifications:

  • Bachelor’s degree in Health Administration, Nursing, or a related healthcare field.
  • 2 years experience in clinical appeals, medical billing, or healthcare claims processing.
  • Strong understanding of medical terminology, clinical documentation, and insurance claim procedures.
  • Proficiency with electronic health records (EHR) systems and claims management software.
  • Excellent written and verbal communication skills. Bilingual (English/Spanish) preferred.

Preferred Qualifications:

  • Master’s degree in Health Administration, Nursing, or a related healthcare field.
  • Certification in Medical Coding (e.g., CPC, CCS) or Healthcare Compliance.
  • Experience working within a health insurance company or healthcare provider setting.
  • Familiarity with regulatory standards such as Florida Medicaid, CMS and HIPAA guidelines.
  • Advanced knowledge of clinical guidelines and payer policies related to appeals.
  • Demonstrated ability to manage multiple appeals simultaneously in a fast-paced environment.

Responsibilities:

  • Demonstrate commitment to Our Mission and models ILS Experience Standards of Excellence.
  • Review and analyze denied or disputed clinical claims to determine the validity and grounds for appeal.
  • Gather and organize relevant clinical documentation, including medical records and physician notes, to support the appeals process.
  • Prepare and submit timely comprehensive appeal letters and supporting documentation to the appealing party.
  • Communicate effectively with internal and external stakeholders to clarify appeal status and or answer questions.
  • Maintain accurate records of all appeals activities and track outcomes to ensure compliance with regulatory requirements and internal policies.
  • Monitor the status of appeals, follow up with the appealing party to ensure timely resolution of cases.
  • Collaborate with clinical and administrative teams to improve processes and reduce the frequency of claim denials.
  • Perform other duties as assigned.



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