Appeals Clinician I

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.

Work from home within Oregon, Washington, Idaho or Utah Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system. Who We Are Looking For: Every day, Cambia’s dedicated team of Appeals Clinicians are living our mission to make health care easier and lives better. As a member of the Health Services Organization team, our Appeals Clinicians utilize clinical expertise to complete the clinical component of all appeal types to resolve member and/or provider appeals – all in service of making our members’ health journeys easier. Are you passionate about being a voice for patients in complex healthcare situations? Do you want to utilize your clinical expertise in a way that impacts thousands of lives? Then this role may be the perfect fit.

Applies nursing expertise and clinical judgement to ensure written appeal decisions are in compliance with medical policy, medical necessity guidelines, reimbursement policies, federal regulation, company policy, industry standard and accepted standards of care. Conducts clinical appeal reviews which adhere to member benefits and provider and hospital contracts. Consults with physician advisers to ensure clinically appropriate determinations when required. Advises and educates non-clinical appeals staff on clinical cases.