Clinical Denials Nurse-Appeals (Remote)

Clinical Denial Appeals Coordinator

Join St. Joseph Regional Medical Center in Lewiston, Idahowhere nationally recognized quality meets small-town heart. We're proud to be recognized for excellence and patient safety, including an "A" Hospital Safety Grade from The Leapfrog Group, inclusion in Becker's list of "Great Community Hospitals," and U.S. News & World Report accolades for maternity care. Here, you'll find a teamwork-first culture, leaders who support you, and coworkers who genuinely have your back. New grads are welcomewe're committed to training, mentoring, and helping you build confidence as you grow. And because we know great care starts with taking care of our people, we offer competitive benefits and a workplace you can feel good about. If you're looking for a place to do meaningful work, build a career, and feel proud serving your communityyou belong at St. Joe's.

Job Summary

The Clinical Denial Appeals Coordinator supports the Revenue Cycle by assessing and utilizing clinical and financial information to obtain optimal reimbursement and assure maximum appropriate payment for the organization. This role partners with patients, physicians, case managers, payers, and other healthcare providers to resolve denials, underpayments, reconsiderations, and appeals. The coordinator identifies trends, educates staff, and contributes to process improvement efforts to minimize denials and optimize resource utilization. This position requires flexibility, strong communication skills, and the ability to represent the organization effectively during appeals and hearings.

Essential Functions

• Assess clinical and financial information concurrently and retrospectively to evaluate medical necessity, level of care, and coverage issues.
• Participate in telephone clinical reviews and multidisciplinary discussions regarding patient care coverage.
• Collaborate with hospital case managers, payers, and reviewers to resolve managed care issues, denials, and appeals.
• Educate hospital staff, case managers, and coders regarding managed care and coding-related denial issues.
• Interact with payer representatives to resolve denial reasons and secure reimbursement.
• Represent the organization in hearings and coordinate representation as appropriate.
• Identify denial trends and refer to appropriate agencies or resources for further action.
• Contribute to process improvement initiatives to reduce denials and improve reimbursement outcomes.
• Complete all required documentation accurately and timely.
• Maintain confidentiality of patient and organizational information.

Knowledge/Skills/Abilities/Expectations

• Strong knowledge of patient billing operations, UB-04, itemized statements, and coding processes.
• Familiarity with denial reasons (medical necessity, technical, financial) and effective resolution strategies.
• Demonstrated understanding of Medicaid, Medicare, commercial insurance, and managed care plans (HMO/PPO).
• Effective verbal and written communication skills.
• Ability to work collaboratively across disciplines and with external organizations.
• Commitment to continuous process improvement.
• Prolonged periods of sitting and working at a computer.
• Occasional standing, walking, and light lifting up to 15 pounds.
• Requires visual acuity to review detailed claim and medical record information.
• Standard office environment within hospital or centralized business office setting.
• Regular interaction with hospital staff, payers, and external agencies.
• Requires ability to manage multiple priorities in a fast-paced environment.

Qualifications

Education

• Minimum: Licensed Practical Nurse (LPN) or three (3) years of clinical denial experience.
• Preferred: Degree in Nursing or Coding Certificate.

Licenses/Certifications

• Relevant clinical or coding certification preferred.

Experience

• Minimum of three (3) years of LPN, clinical denial management or related healthcare revenue cycle functions.
• Experience in working with insurance plans, denials, reconsiderations, and appeals preferred.
• Preferred experience in nursing, case management, or health information management.