Appeals Nurse

Job Description

Job Description

Description:

Job Title: Appeals Nurse

Company: Physician Care Coordination Consultants (PC3)

Location: Remote

Job Type: Full-time

Job Classification:

This is an exempt position under the Fair Labor Standards Act (FLSA) and is not eligible for overtime pay.

Our Mission:

Our mission is to drive financial wellness in healthcare organizations so more patients can receive the care they need. 

Our Vision:

Our vision is a future where we help healthcare organizations thrive in a complex ecosystem by clearing a path to financial health. 

Our Culture:

We are committed to creating a workplace where every member feels valued, empowered, and inspired to contribute their best. Together we will foster a culture that promotes work-life balance and celebrates community engagement, personal achievements, milestones, and special occasions. 

Values:

•   Integrity – We do what’s right, no matter what. 
•   Innovation – We use a harmonious blend of data, tech, and a human-centric approach. 
•   Compassion – We understand the stress of healthcare organizations and their patients.
•   Determination – Our mission is our guiding force. 
• Partnership – We build enduring relationships through listening, communication and accountability.
• Dignity: We have significant pride in each other and our work. 

Job Summary:

The Appeals Nurse is responsible for reviewing denied medical claims and services to determine if the denial should be overturned based on clinical documentation and medical necessity. This role involves interpreting medical records, applying clinical judgment, and preparing appeal letters or case summaries to support patient care decisions. The Appeals Nurse works closely with physicians, case managers, and insurance companies to ensure timely and accurate resolution of appeals.

This position reports directly to the Associate Director of Revenue Cycle Management

Duties/Responsibilities:

Review denied claims and medical records for completeness, accuracy, and compliance with payer guidelines.

Conduct clinical evaluations and assess the medical necessity of services rendered.

Prepare and submit written appeals, reconsideration requests, and supporting documentation.

Collaborate with healthcare providers and payers to gather necessary information and clarify case details.

Stay current with clinical guidelines, payer policies, and regulatory requirements.

Track appeal outcomes and maintain detailed records for compliance and auditing.

Participate in quality improvement initiatives related to utilization review and appeals.

Provide clinical input to support the organization’s efforts in reducing claim denials.

Requirements:

Knowledge/ Skills/Abilities:

Strong knowledge of clinical documentation, insurance guidelines, and medical necessity criteria (e.g., InterQual, Milliman)

Excellent analytical, critical thinking, and problem-solving skills

Effective written and verbal communication skills

Proficiency with electronic health records (EHR) and claims systems

Ability to manage time effectively and work independently or as part of a team

High level of attention to detail and accuracy

Education and Experience:

Education: Associate Degree required. Bachelor's degree preferred in nursing (ADN or BSN)

Licensure: Active and unrestricted RN license in [state or compact license as applicable]

Experience: Minimum of 5 years of clinical nursing experience required. Experience in utilization review, case management, or appeals preferred

Certifications: Certification in Case Management (CCM) or Utilization Review (URAC) is a plus

Physical Requirements:

Prolonged periods of sitting at a desk and working on a computer.

Must be able to lift up to 15 pounds at times.