Clinical Appeals Nurse

Job Summary

Working remotely in a full-time capacity, the Clinical Appeals Nurse will review payor denials, write comprehensive appeal letters, and serve as a liaison with third-party payors to facilitate claims appeals.

Key responsibilities

• Reviews payor denials and audits to identify potential revenue loss and prepares appeal letters based on medical policy guidelines
• Coordinates with the physician advisor team and communicates with insurance companies to conduct appeals via telephone or email
• Monitors and reports payor trends to management while ensuring compliance with regulatory and accrediting requirements

Required qualifications

• Current nursing license in the relevant state
• Experience in clinical appeals or related healthcare field
• Knowledge of medical necessity criteria and insurance processes
• Strong analytical skills to review claim documentation and supporting medical evidence
• Ability to work independently in a remote environment