ZipRecruiter

Log In

1

Clinical Appeals Jobs (NOW HIRING)

Independence Blue Cross

Supervisor Appeals

Philadelphia, PA · On-site

$22.25 - $27.50/hr

Position Summary The Appeals Supervisor oversees day-to-day operations of the administrative (non-clinical)appeals. This role ensures timely, accurate, and compliant processing of member and provider ...

UnitedHealth Group

Clinical Appeals RN

Boston, MA · Remote

$28.94 - $51.83/hr

The Clinical Appeals RN is responsible for attending appeal hearings, defending MassHealth prior authorization decisions, and performing pre-service/prior authorization clinical coverage review of ...

UnitedHealth Group

Clinical Appeals RN

Boston, MA · On-site

$28.94 - $51.83/hr

The Clinical Appeals RN is responsible for attending appeal hearings, defending MassHealth prior authorization decisions, and performing pre-service/prior authorization clinical coverage review of ...

next page

Showing results 1-20

All JobsClinical Appeals Jobs

Clinical Appeals information

See salary details

$30K

$69.5K

$121K

How much do clinical appeals jobs pay per year?

As of Aug 2, 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, and why are they important?

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.
More about Clinical Appeals jobs
What cities are hiring for Clinical Appeals jobs? Cities with the most Clinical Appeals job openings:
What are the most commonly searched types of Clinical Appeals jobs? The most popular types of Clinical Appeals jobs are:
What states have the most Clinical Appeals jobs? States with the most job openings for Clinical Appeals jobs include:
What job categories do people searching Clinical Appeals jobs look for? The top searched job categories for Clinical Appeals jobs are:
Clinical Appeals jobs near you
Infographic showing various Clinical Appeals job openings in the United States as of July 2026, with employment types broken down into 12% Locum Tenens, 80% Full Time, 6% Part Time, and 2% Contract. Highlights an 79% Physical, 6% Hybrid, and 15% Remote job distribution, with an average salary of $69,454 per year, or $33.4 per hour.

Manager, Clinical Appeals

Health Business Solutions LLC

Cooper City, FL • Remote

Full-time

Re-posted 19 days ago

Job description

Job Summary:

We are seeking an experienced and highly organized Manager of Clinical Appeals to lead our clinical appeals operations across commercial and government payers. This role is responsible for overseeing day-to-day activities of clinical appeal specialists, managing appeal strategy execution, ensuring quality and compliance, and meeting client-specific performance goals.

The ideal candidate brings a strong background in clinical review, medical necessity denials, payer appeal processes, and team leadership—ideally across both U.S. and offshore teams (e.g., Philippines). This position is critical to ensuring timely and effective resolution of denied claims, supporting revenue recovery efforts, and maintaining payer and regulatory compliance.

Key Responsibilities:

  • Manage the full-cycle clinical appeals process across multiple payer types, with a focus on government (e.g., Medicare, Medicaid) and commercial payers.
  • Lead and support a team of nurses, clinical reviewers, and appeal specialists—including potential offshore (Philippines-based) staff.
  • Monitor appeal workloads, productivity, and turnaround times to ensure all appeal deadlines and client service level agreements (SLAs) are met.
  • Review and approve complex or high-value clinical appeal cases, ensuring clinical accuracy and compliance with payer guidelines.
  • Maintain up-to-date knowledge of medical necessity criteria, payer policies, NCDs/LCDs, and applicable CMS regulations.
  • Train new and existing team members on clinical guidelines, appeal writing standards, and regulatory requirements.
  • Work cross-functionally with audit, legal, compliance, and operations teams to align on strategy and escalate trends or systemic payer issues.
  • Identify and implement process improvements to increase efficiency, reduce denials, and improve overturn rates.
  • Support the creation and refinement of appeal templates, clinical arguments, and documentation standards.
  • Generate and deliver performance and quality reports to leadership, identifying risks and opportunities for improvement.

Qualifications:

  • Registered Nurse (RN) or clinical degree required; Bachelor's degree in Nursing, Health Administration, or related field preferred.
  • 5+ years of experience in clinical appeals, utilization review, or medical necessity denials.
  • 2+ years in a leadership or supervisory role, preferably within a revenue cycle or payer appeals setting.
  • In-depth understanding of payer denial processes, especially Medicare Advantage, Medicaid Managed Care, and commercial plans.
  • Experience managing remote and/or offshore teams (Philippines experience preferred).
  • Strong working knowledge of ICD-10, CPT, and HCPCS coding as they relate to clinical justifications.
  • Excellent writing skills and the ability to clearly communicate complex clinical reasoning.
  • Familiarity with appeal submission portals, EHRs, and workflow platforms.
  • Knowledge of HIPAA, CMS, and NCQA standards.

Apply