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Clinical Appeals Rn Jobs in California (NOW HIRING)

TNAA TotalMed RN

Travel RN Case Manager

Oakland, CA · On-site

Communicate with Insurance companies to collaborate or appeal decisions. * Improve financial status ... clinicians of all specialties in all 50 states. They offer local and travel jobs and match ...

TNAA TotalMed RN

Travel Case Manager RN

Torrance, CA · On-site

Communicate with Insurance companies to collaborate or appeal decisions. * Improve financial status ... clinicians of all specialties in all 50 states. They offer local and travel jobs and match ...

TNAA TotalMed RN

Travel Case Manager RN

Burbank, CA · On-site

Communicate with Insurance companies to collaborate or appeal decisions. * Improve financial status ... clinicians of all specialties in all 50 states. They offer local and travel jobs and match ...

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Clinical Appeals Rn information

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$56

How much do clinical appeals rn jobs pay per hour?

As of Aug 27, 2026, the average hourly pay for clinical appeals rn in California is $38.04, according to ZipRecruiter salary data. Most workers in this role earn between $30.82 and $42.69 per hour, depending on experience, location, and employer.

What is a Clinical Appeals RN?

A Clinical Appeals RN is a registered nurse who reviews denied medical claims and submits appeals to insurance companies to ensure appropriate reimbursement. They analyze medical records, insurance policies, and clinical guidelines to justify the necessity of treatments or procedures. This role requires strong knowledge of healthcare regulations, excellent critical thinking skills, and experience in case management or utilization review.

What does a Clinical Appeals RN do?

A typical day for a Clinical Appeals RN involves reviewing denied insurance claims, gathering and evaluating clinical documentation, composing argument letters, and communicating with healthcare providers and payers to support appeal cases. You may participate in multidisciplinary meetings to discuss complicated cases and must often manage multiple appeals at different stages of the process. The work is largely independent, though collaboration with physicians, case managers, and insurance representatives is common. Strong organization and time management skills are important to keep up with deadlines and ensure the best possible outcomes for patients.

What are the key skills and qualifications needed to thrive as a Clinical Appeals RN?

A Clinical Appeals RN requires current RN licensure, comprehensive clinical knowledge, and experience with utilization review or case management. Familiarity with healthcare claims, appeals processes, and specialized systems such as InterQual or Milliman, as well as strong documentation skills, are often essential. Excellent critical thinking, persuasive writing, and collaboration skills set top candidates apart. These skills ensure accurate, timely, and effective advocacy in the appeals process, leading to favorable outcomes for patients and healthcare organizations.

How to get into clinical appeals in nursing?

To become a Clinical Appeals RN, gain experience in medical-surgical or case management nursing, develop strong knowledge of insurance policies and medical documentation, and obtain relevant certifications such as Certified Case Manager (CCM) or Nurse Case Manager (CCM). Familiarity with electronic health records and strong communication skills are also essential for handling appeals effectively.

What are popular job titles related to Clinical Appeals Rn jobs in California?

For Clinical Appeals Rn jobs in California, the most frequently searched job titles are:

What job categories do people searching Clinical Appeals Rn jobs in California look for?

The top searched job categories for Clinical Appeals Rn jobs in California are:

Clinical Appeals Rn jobs near you
Infographic showing various Clinical Appeals Rn job openings in California as of August 2026, with employment types broken down into 2% As Needed, 71% Full Time, 18% Part Time, and 9% Contract. Highlights an 85% Physical, 1% Hybrid, and 14% Remote job distribution, with an average salary of $79,124 per year, or $38 per hour.

Clinical Appeals RN

Santa Ana, CA • On-site

KPC GLOBAL MEDICAL CENTERS INC.
Health Care and Social Assistance • 201 - 500 employees
Learn more about KPC GLOBAL MEDICAL CENTERS INC.external

$51.50 - $61.80/hr

Other

Posted 6 days ago

Job description

SUMMARY

 The Clinical Appeals Nurse is responsible for investigating and processing medical necessity appeals from members and providers to payers. Possesses the ability to conduct research on standards or practice, regulations, and policy relevant to any case. Responsible for overturning denied claims, upholding the denials and submitting cases to the Medical Director for review. Possesses the ability to communicate clearly and concisely, both verbally and in writing and utilize computer and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Ensures timely and accurate processing of all denials. Will ensure that denials are processed according to KPC Policies and meet all Health Plan, Federal and State requirements. Perform other duties as assigned.

REQUIREMENTS

  • Current active California RN license required
  • Minimum 2 years of experience in a managed care healthcare setting
  • Minimum 2 years of Utilization Management
  • Experience with payer specific medical guidelines and how to apply them in an appeal
  • Experience using MCG and/or InterQual guidelines

DUTIES AND RESPONSIBILITIES

  • Conduct and investigate member and provider medical necessity appeals
  • Review prospective, inpatient, and retrospective medical records of denied services for medical necessity
  • Ensures appeals and grievances are resolved in a timely manner
  • Prepare clinical reviews and provides monitoring of cases involving medical decisions and quality of services and care
  • Generate written correspondence to providers and members to achieve maximum overturn rate
  • Provide input into corrective action plans for clinical and service events to improve decision-making or quality of care and services for internal and provider partner decisions
  • Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
  • Presents recommendations based on clinical review, criteria, and organizational policies
  • Complies with HIPAA and other compliance requirements to protect patient confidentiality
  • Contact and educate patients and guarantors regarding necessary steps to resolve an outstanding insurance balance while providing exemplary customer service
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About KPC Health

Sourced by ZipRecruiter

KPC Health has an integrated approach to serving the people of Riverside, San Bernardino and Orange County. Our acute care medical centers provide high quality, comprehensive and affordable healthcare for the entire family. For us, healthcare is not just about caring for our patients, but also about investing in the people throughout our communities. We are one team with one mission and that mission is for all our patients, and their families to Enjoy Life in Great Health.

Industry

Health care and social assistance

Company size

201 - 500 Employees

Headquarters location

Santa Ana, CA, US

Year founded

2004

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