Medical Review Nurse – Risk & Appeals

At Allstate, great things happen when our people work together to protect families and their belongings from life’s uncertainties. And for more than 90 years, our innovative drive has kept us a step ahead of our customers’ evolving needs. From advocating for seat belts, air bags and graduated driving laws, to being an industry leader in pricing sophistication, telematics, and, more recently, device and identity protection. Job DescriptionAbout the RoleAre you a clinically experienced Registered Nurse looking to apply your expertise beyond direct patient care?As a Medical Review Nurse you will play a critical role in strengthening risk management and improving decision-making across our health and accident products. You’ll use your clinical knowledge to evaluate medical records, guide coverage determinations, and support fair, evidence-based appeal outcomes—directly impacting both business outcomes and member experience.This is an opportunity to bring your clinical judgment, analytical thinking, and passion for quality care into a dynamic, fast-paced environment where your insights drive meaningful results.What You’ll DoServe as a trusted clinical expert supporting accident and health lines of businessReview medical records and claims to determine coverage and benefit eligibilityEvaluate medical necessity and appropriateness of care based on evidence-based guidelinesDraft clear, defensible written rationales for coverage and appeal determinationsAnalyze medical and claims data to identify trends, risks, and improvement opportunitiesAssess medical information to determine current and potential risk exposure for coverage decisionsInterpret and apply policy contract language to ensure consistent, accurate determinationsSynthesize complex data from multiple sources to inform business decisionsMaintain strong productivity and quality in a high-volume, fast-paced environmentCollaborate cross-functionally while demonstrating strong independence and accountabilityWhat You BringRequiredActive Registered Nurse (RN) licenseProven ability to analyze and interpret complex medical information and documentationStrong clinical judgment and decision-making skillsExcellent written and verbal communication skillsPreferred5+ years of clinical nursing experienceExperience in health insurance, utilization review, medical claims, or appealsFamiliarity with medical coding systems (CPT, ICD-10, HCPCS) and claims documentationExperience interpreting insurance policy language and applying it in decision-makingExposure to data analysis and identifying trends within medical or claims dataKey Skills & StrengthsAnalytical mindset with strong attention to detailAbility to translate clinical complexity into clear, actionable insightsStrong problem-solving and critical thinking capabilitiesEffective time management and ability to prioritize competing demandsComfortable working both independently and collaborativelyTools & ExpertiseProficiency in Microsoft Office (Excel, Word, Outlook)Experience working with medical records, physician notes, and evidence-based clinical studiesAbility to interpret Explanation of Benefits (EOBs) and submitted claimsWhy Join UsImpact: Your clinical expertise directly influences fair, data-driven decisions that affect members and the businessGrowth: Expand your career beyond bedside care into analytics, risk management, and insuranceFlexibility: Work in a collaborative, fast-paced corporate environment with opportunities to deepen your expertisePurpose: Help ensure accurate, evidence-based decisions that support better outcomesSkillsClinical Experience, Clinical Knowledge, Communication, Critical Thinking, Decision Making, Problem SolvingCompensationCompensation offered for this role is 62,100.00 - 103,950.00 annually and is based on experience and qualifications.The candidate(s) offered this position will be required to submit to a background investigation. Joining our team isn’t just a job — it’s an opportunity. One that takes your skills and pushes them to the next level. One that encourages you to challenge the status quo. One where you can shape the future of protection while supporting causes that mean the most to you. Joining our team means being part of something bigger – a winning team making a meaningful impact.Allstate generally does not sponsor individuals for employment-based visas for this position.Effective July 1, 2014, under Indiana House Enrolled Act (HEA) 1242, it is against public policy of the State of Indiana and a discriminatory practice for an employer to discriminate against a prospective employee on the basis of status as a veteran by refusing to employ an applicant on the basis that they are a veteran of the armed forces of the United States, a member of the Indiana National Guard or a member of a reserve component.For jobs in San Francisco, please click “here” for information regarding the San Francisco Fair Chance Ordinance.For jobs in Los Angeles, please click “here” for information regarding the Los Angeles Fair Chance Initiative for Hiring Ordinance.To view the “EEO Know Your Rights” poster click “here”. This poster provides information concerning the laws and procedures for filing complaints of violations of the laws with the Office of Federal Contract Compliance Programs.To view the FMLA poster, click “here”. This poster summarizing the major provisions of the Family and Medical Leave Act (FMLA) and telling employees how to file a complaint.It is the Company’s policy to employ the best qualified individuals available for all jobs. Therefore, any discriminatory action taken on account of an employee’s ancestry, age, color, disability, genetic information, gender, gender identity, gender expression, sexual and reproductive health decision, marital status, medical condition, military or veteran status, national origin, race (include traits historically associated with race, including, but not limited to, hair texture and protective hairstyles), religion (includin