Medical Review Nurse – Risk & Appeals

About the role

Allstate is seeking a clinically experienced Registered Nurse to join its Risk & Appeals team. In this role you will apply your nursing expertise to evaluate medical records, guide coverage decisions, and support fair appeal outcomes for health and accident products.

Key responsibilities

• Serve as a trusted clinical expert for accident and health lines of business.
• Review medical records and claims to determine coverage and benefit eligibility.
• Evaluate medical necessity using evidence‑based guidelines.
• Draft clear, defensible rationales for coverage and appeal determinations.
• Analyze medical and claims data to identify trends, risks, and improvement opportunities.
• Assess risk exposure based on medical information for coverage decisions.
• Interpret and apply policy contract language consistently.
• Synthesize data from multiple sources to inform business decisions.
• Maintain high productivity and quality in a fast‑paced environment.
• Collaborate cross‑functionally while demonstrating independence and accountability.

Required profile

• Active Registered Nurse (RN) license.
• Proven ability to analyze and interpret complex medical information.
• Strong clinical judgment and decision‑making skills.
• Excellent written and verbal communication abilities.

Required skills

• Analytical mindset with strong attention to detail.
• Ability to translate clinical complexity into clear, actionable insights.
• Problem‑solving and critical‑thinking capabilities.
• Effective time management and prioritization.
• Comfortable working both independently and collaboratively.

What we offer

• Opportunity to influence risk management and member experience.
• Dynamic, fast‑paced environment with cross‑functional collaboration.