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 Description
About the Role Are 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 Do Serve as a trusted clinical expert supporting accident and health lines of business Review medical records and claims to determine coverage and benefit eligibility Evaluate medical necessity and appropriateness of care based on evidence-based guidelines Draft clear, defensible written rationales for coverage and appeal determinations Analyze medical and claims data to identify trends, risks, and improvement opportunities Assess medical information to determine current and potential risk exposure for coverage decisions Interpret and apply policy contract language to ensure consistent, accurate determinations Synthesize complex data from multiple sources to inform business decisions Maintain strong productivity and quality in a high-volume, fast-paced environment Collaborate cross-functionally while demonstrating strong independence and accountability What You Bring Required Active Registered Nurse (RN) license Proven ability to analyze and interpret complex medical information and documentation Strong clinical judgment and decision-making skills Excellent written and verbal communication skills Preferred 5+ years of clinical nursing experience Experience in health insurance, utilization review, medical claims, or appeals Familiarity with medical coding systems (CPT, ICD-10, HCPCS) and claims documentation Experience interpreting insurance policy language and applying it in decision-making Exposure to data analysis and identifying trends within medical or claims data Key Skills & Strengths Analytical mindset with strong attention to detail Ability to translate clinical complexity into clear, actionable insights Strong problem-solving and critical thinking capabilities Effective time management and ability to prioritize competing demands Comfortable working both independently and collaboratively Tools & Expertise Proficiency in Microsoft Office (Excel, Word, Outlook) Experience working with medical records, physician notes, and evidence-based clinical studies Ability to interpret Explanation of Benefits (EOBs) and submitted claims
Why Join Us
Impact: Your clinical expertise directly influences fair, data-driven decisions that affect members and the business Growth: Expand your career beyond bedside care into analytics, risk management, and insurance Flexibility: Work in a collaborative, fast-paced corporate environment with opportunities to deepen your expertise Purpose: Help ensure accurate, evidence-based decisions that support better outcomes Skills Clinical Experience, Clinical Knowledge, Communication, Critical Thinking, Decision Making, Problem Solving
Compensation
Compensation 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 (including religious dress), sex, or sexual orientation that adversely affects an employee's terms or conditions of employment is prohibited. This policy applies to all aspects of the employment relationship, including, but not limited to, hiring, training, salary administration, promotion, job assignment, benefits, discipline, and separation of employment. Allstate provides a comprehensive technology setup, including a laptop, monitors, headset, keyboard, and mouse. Employees eligible to work from home also receive a monthly connectivity reimbursement to help offset internet costs. When working from home, you must have a dedicated, private workspace free from distractions, along with appropriate desk and seating. Reliable internet is required, with minimum speeds of 50 MB download and 5 MB upload.