Specialist, Clinical Appeals (RN)
Specialist, Clinical Appeals (RN)
Posted on :
30-08-2025
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1 Vacancy
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Job Description
- Clinical Denial Review and Analysis:
- Perform comprehensive reviews of denied claims focusing on clinical issues such as medical necessity level of care non-covered services and authorization-related denials.
- Conduct thorough analysis of patient medical records payer medical policies and relevant medical necessity criteria (e.g. InterQual Milliman) to build a robust clinical case for appeal.
- Identify gaps in clinical documentation and collaborate with other team members to gather the necessary supporting evidence for a successful appeal.
- Appeal Generation and Submission:
- Independently write professional persuasive appeal letters that present a compelling clinical argument for payment.
- Leverage generative AI tools to assist in drafting initial appeal letters increasing efficiency and allowing focus on the most complex cases.
- Ensure all appeals are submitted accurately within payer-specific timelines and tracked through to final resolution in the Pulse platform.
- Collaboration and Process Improvement:
- Work closely with the Payer Contract Specialist Certified Coders and Revenue Recovery Specialists to ensure a holistic and coordinated approach to each appeal.
- Identify and report emerging denial trends to team leadership to support root cause analysis and the development of denial prevention strategies.
- Assist in creating and maintaining standardized appeal letter templates for various denial types and payers to improve team efficiency.
KNOWLEDGE SKILLS AND ABILITIES:
- Strong clinical acumen with the ability to critically analyze medical records and justify the medical necessity of services rendered.
- Exceptional written communication skills with the ability to craft clear concise and persuasive arguments.
- Technologically proficient and comfortable learning and mastering new software; experience with EHR/EMR systems is essential.
- Comfortable navigating and troubleshooting various applications including Microsoft Office Suite data management systems and virtual collaboration tools.
- Highly organized self-motivated and able to work independently to manage a caseload and meet deadlines.
- Familiarity with medical billing coding principles (ICD-10 CPT) and payer reimbursement methodologies.
WORK EXPERIENCE EDUCATION AND CERTIFICATIONS:
Active and unrestricted Registered Nurse (RN) license.
Bachelor of Science in Nursing (BSN) preferred.
Previous experience in denial management or clinical appeals role.
Minimum of 2-3 years of clinical experience in a hospital or healthcare setting. Experience in Case Management Utilization Review or Clinical Documentation Improvement (CDI) is highly desirable.
Technologically proficient and comfortable learning and mastering new software; experience with EHR/EMR systems is essential.
WORKING CONDITIONS AND PHYSICAL REQUIREMENTS:
- 100% Remote
- Reliable high-speed internet connection is required for all remote/hybrid positions.
- Must have access to stable Wi-Fi with sufficient bandwidth to support video conferencing cloud-based tools and other online work-related activities.
- A HIPAA-compliant work environment is required including a secure workspace free from unauthorized access or interruptions no use of public Wi-Fi unless connected through a secure company-provided VPN and compliance with all applicable HIPAA privacy and security regulations.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
Key Skills
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