Registered Nurse Clinical Appeals

Job Summary

Working remotely in a full-time capacity, the Registered Nurse Clinical Appeals will conduct medical necessity reviews, perform retrospective medical record evaluations, and manage clinical appeals while collaborating with various teams to resolve denials and improve processes.

Key responsibilities

• Conduct pre and post service medical necessity reviews for various hospital encounters using evidence-based criteria
• Prepare, submit, and track clinical appeals, ensuring compliance with payer policies and regulations
• Collaborate with cross-functional teams to identify denial root causes and implement recommendations for process improvement

Required qualifications

• Current unrestricted Registered Nurse license in the state of residence
• Bachelor's degree with 4-6 years of relevant acute care clinical experience, or an Associate's degree with 6-8 years of experience
• Experience in clinical denials, utilization review, case management, or appeals
• Familiarity with InterQual and/or Milliman Care Guidelines
• Strong knowledge of hospital revenue cycle workflows and payer regulations