Clinical Appeals RN
Company: KPC GLOBAL MEDICAL CENTERS INC.
Role summary
Clinical Appeals RN is a role at KPC GLOBAL MEDICAL CENTERS INC. in Santa Ana, California, United States (on-site). Posted 2026-08-20. Salary: USD 52–62 per hour. Experience level: 2-5.
- Job title
- Clinical Appeals RN
- Company
- KPC GLOBAL MEDICAL CENTERS INC.
- Location
- Santa Ana, California, United States
- Work arrangement
- on-site
- Category
- Healthcare Support
- Salary
- USD 52–62 per hour
- Experience level
- 2-5
- Date posted
- 2026-08-20
You can earn a competitive hourly rate with this flexible per diem role that focuses on the clinical side of the healthcare revenue cycle. It is a great opportunity to move away from direct bedside care while using your nursing expertise to advocate for patients and ensure claims are handled correctly.
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
Apply for Clinical Appeals RN at KPC GLOBAL MEDICAL CENTERS INC.