Clinical Appeal Nurse

**Major Responsibilities:** * Utilize clinical nursing expertise to assess denied claims for timely evaluation and determine eligibility for appeal using established clinical level-of-care criteria, documentation of medical necessity, and appropriateness of status order. * In-depth knowledge of CMS regulations and other federal, state, and payer-specific compliance requirements and government audit protocols. * Utilize industry guidelines, Medicare Benefit Policy Manual, national and local coverage determinations, and best practice standards, applying sound clinical judgment in reviewing medical records and completing appeals. * Research and analyze denied claims using payer and government rules and regulations to determine appeal eligibility based on third-party requirements. * Leverage AI-driven tools and technologies to enhance appeal writing efficiency, ensure accuracy, and support data-driven decision-making in denial management. * Continue the appeal process until the case is overturned, appeal options are exhausted, or a decision is made to discontinue, ensuring ongoing documentation of denial status in denial software. * Prepare clinical appeals for authorization, coding, level of care, medical necessity, and/or length of stay denials. * Prioritize appeals according to filing limitations established by individual payer contracts and/or governmental bodies. Secure required medical documentation from providers or request from insurance carriers to support the appeal process. * Work to minimize payer denials by identifying trends and partnering with departments such as Denial Avoidance, Billing Operations, Pre-Service, Case Management, Utilization Management, Contracting, Audit, other Revenue Cycle teams, and physician advisors to provide education and corrective action for errors related to admission, charging, coding, documentation, patient status, or billing. * Communicate denial issues, patterns and barriers impacting claim payment to the Clinical Appeal RN Lead, to present during payer meetings to facilitate resolution as applicable. * Escalate to Revenue Recovery leadership to coordinate cross-functional teams in implementing denial prevention strategies and enhancing financial sustainability. **Licensure:** * Current, unrestricted RN license. **Education/Experience Required:** * Bachelor’s Degree in Nursing or Associate Degree Nursing with a Bachelor of Science Degree * Minimum 3 years clinical experience in acute care. Preferred experience in utilization review, case management, denials/appeals/government audits, or revenue cycle. **Knowledge, Skills & Abilities Required**: * Excellent critical thinking and analytical skills, with a high attention to detail. * Ability to meet deadlines while independently working in a fast-paced environment. * Proficiency with Microsoft Office and Epic; experience with denial management software. * Experience with CPT and HCPCS coding nomenclature, ICD-10 coding conventions, clinical documentation standards, and reimbursement methodologies. * Previous clinical/technical documentation and chart review experience along with understanding of medical terminology. * Knowledge of appeals criteria and understanding of federal, state and local regulations. * Experience with level of care criteria (MCG and/or InterQual), Medicare Guidelines - NCD (National Coverage Determination) and LCD (Local Coverage Determination), and clinical documentation standards. * Ability to take initiative and work collaboratively with others. * Strong computer skills, including high proficiency with Microsoft Office Suite. * Excellent writing skills are necessary to facilitate the advanced appeal process. **Physical Requirements and Working Conditions:** Fully remote work environment