Full-Time Clinical Appeals Nurse

The Clinical Appeals Nurse manages medical denials by reviewing clinical documentation to determine medical necessity. They consult with providers, patients, and medical records to create sound appeal arguments. They manage the appeals process within deadlines.

Essential Duties and Responsibilities:

• Successfully manage the appeals process from start to finish.
• Ensure appropriate communication with patients, insurance companies, and internal partners.
• Maintain HIPAA compliance.
• Perform other duties as assigned.

Job Expectations:

• Determine denial reasons and appeal necessity using payer requirements and medical charts.
• Develop appeal arguments using criteria, evidence, and resources.
• Generate appeal resolution communications following company policy.
• Request provider information to expedite appeals.
• Prepare case information for Administrative Law hearings.
• Summarize appeal outcomes and participate in client meetings.
• Review documentation related to level of care decisions with clients.

Minimum Knowledge, Skills, and Abilities:

• Bachelor's Degree in Nursing
• Current MO RN license
• 4 years' experience as a clinical nurse in an acute care setting
• Knowledge of third-party payer regulations
• Analytical, creative, and interpersonal skills
• Excellent communication skills (written, verbal, and presentation)
• Strong clinical and regulatory knowledge, including payer requirements
• Strong organizational skills
• Sense of urgency

Preferred Qualifications:

• 2 years' experience in case management, discharge planning, or utilization review
• Experience with infusion, home health, and managed care
• Experience working with patients with rare chronic disorders
• Positive attitude, genuine interest in others, and sense of humor
• Commitment to teamwork, motivation of others, and creative problem-solving
• Integrity, credibility, and high ethical standards

Physical/Mental Demands and Working Environment:

• Primarily sedentary, with periods of standing or sitting (up to 90%).
• Regular talking, hearing, typing, repetitive motions, reaching, grasping, and occasional lifting (up to 25 lbs).
• Occasional stooping, crouching, pushing/pulling, and kneeling.
• Specific vision abilities including close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
• Mental alertness, verbal/written communication, concentration, detail-oriented, adaptability, stress management, and analytical thinking.
• Professional office environment with moderate noise level and frequent interruptions.

Compensation: $67,500 - $94,000 (US Locations only). Compensation based on experience and location.

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