Clinical Appeals Nurse (PRN)

Responsible for reviewing medical records and preparing clinical appeals in response to medical necessity denials and diagnosis-related groups (DRG) reassignments Responsibilities

* Prepare and submit clinical appeals in response to denials from managed care organizations, governmental entities, and Recovery Audit Contractors (RACs) for hospital clients * Review medical records and utilize industry guidelines, Medicare policies, and best practice standards to support appeal arguments * Participate in Administrative Law Judge (ALJ) Hearings, presenting oral arguments to support the reversal of Medicare denials * Analyze denial patterns and contribute insights to help reduce future denials * Collaborate with the appeals team and hospital clients to provide updates on appeal statuses and outcomes * Maintain current knowledge of healthcare regulations, coding guidelines, and payer policies relevant to the appeals process

Qualifications Required

* Bachelor's of Science in Nursing (BSN) or equivalent degree * Current and unrestricted RN license * At least 5 years of clinical experience in acute care settings * At least 3 years of experience in case management, utilization review, or clinical appeals * Exceptional written and verbal communication skills * Proficiency with MS Office suite, particularly Word and Excel * Strong analytical and problem-solving skills with attention to detail

Preferred

* Experience with payer-side case management or medical director-level review

Expectations

* Comfortable with remote work arrangements and virtual collaboration tools * May require occasional travel for conferences, client meetings, or in-person hearings * Physical demands include extended periods of sitting, computer use, and telephone communication

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