RN Clinical Appeals Specialist

Come work at the best place to give and receive care! Job Description: Who We Are: This department takes great pride in the work that we do. We ensure to provide a very welcoming and supportive environment; where everyone can thrive. About the Job: The Nurse Appeals Specialist is responsible for completing a thorough evaluation of clinical documentation to support the resolution and prevention of payer denials. This position will examine denials from payers based on billing accuracy, medical necessity, coding, and other key modifiers; and will create compelling appeal arguments based on the clinical documentation and payers’ medical policies. The Nurse Appeals Specialist collaborates with clinical and revenue cycle teams to identify root causes of denials and contributes to staff education and process improvements aimed at reducing future denials and enhancing revenue integrity. What You’ll Do: Review clinical denials and initiate appeals process in accordance with internal guidelines and payer specific requirements. Conduct thorough medical record reviews and prepare clinical summaries to support appeal submissions, ensuring alignment with payer policies. Communicate with payer representatives, legal counsel, and other stakeholders throughout the appeal process. Present appeals to Administrative Law Judges when appropriate. Monitor appeals through all stages, determine next steps, and ensure timely resolution or escalating to the highest level of review. Assist billing and case management teams in reviewing high-risk or high-dollar accounts prior to claim submission. Analyze denial data to identify patterns and root causes and share insights with Revenue Cycle leadership to inform process improvements and reduce future denials. Draft customized appeal letters based on denial rationale and clinical documentation, ensuring clarity, accuracy, and compliance with payer guidelines. Apply national clinical guidelines (e.g., InterQual, Milliman Clinical Guidelines) to determine appropriate status determination and support appeal arguments. Assess reimbursement risk based on payer interactions and escalates complex or recurring issues to management with support data for resolution. Ensure all appeal activities are documented and completed within required timeframes, coordinating internal and external resources as needed. Participate in ongoing training to stay current with system updates, policy changes, and best practices in coding, billing, and denial management. Meet or exceed established key performance indicators for assigned responsibilities. Maintain current certification and/or licensure as required by federal and state regulations, as well as organizational policies, to ensure continued eligibility and compliance in the role. Understands and carries out organizational policies and procedures. Embraces a growth mindset and possesses critical thinking skills. Ensure confidentiality of employee, legal, client/patient, budget and all company matters. Participate in Elliot Health System work groups and in-services as appropriate. Master new software programs quickly and independently. Perform other duties as assigned. Who You Are: Education: Associate Degree in Nursing and 3+ years in medical coding or billing Current permanent U.S. work authorization required. Bachelor of Science in Nursing preferred. License: Applicable RN license. Certified coding credentials (CPC, CPC-H, CCS, CCS-P, RHIT, or RHIA) Experience: Three (3) to five (-5) plus years of auditing and coding experience. Experience with medical chart review. Knowledge: Thorough knowledge of ICD-10 CM, CPT, DRG methodologies and all regulatory requirements associated with coding and DRG assignment. Knowledge of medical terminology, payer rules/regulations, and CDM guidelines. Knowledge of billing issues and reimbursements Knowledge of advanced nursing principles. Epic Coding, HIM, and Revenue Integrity application experience. Skills: Familiarity with Microsoft office (Word, PowerPoint, Excel) Abilities: Ability to review and analyze issues related to coding, billing, and medical record documentation. Ability to proceed independently following standard practices and procedures, referring questions or issues to the supervisor. Ability to utilize time management and project management skills to permit handling of large workloads. High attention to detail and commitment to accuracy, data integrity, and quality improvement. Excellent research and analytical skills for trending and analysis. Effective verbal and written communication skills to collaborate with peers, providers, leadership, and other hospital personnel. Ability to receive and apply feedback to improve quality and productivity. High degree of flexibility and resilience to adapt to organizational change, shifting priorities, and evolving healthcare regulations. Possesses a growth mindset, critical thinking skills, and is root cause and correct focused. Familiarity with technology and data tools, including Epic, Microsoft Excel, and coding, billing, and appeals software. Ability to develop and maintain effective relationships throughout the organization to support operational goals and outcomes. Commitment to patient confidentiality and regulatory compliance, consistently modeling professional standards and ethical behavior Why You’ll Love Us: Health, dental, prescription, and vision coverage for full-time & part-time employees Short-term, long-term disability, life & pet insurance Tuition reimbursement & Nursing Student Loan Paydown Program 403(b) Retirement savings plans Continuous earned time accrual We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, disability status, veteran status, or any other characteristic protected by law. Work Shift: The schedule is 8 hours per day and can be worked anytime between 7:00 a.m. and 6:00 p.m., Monday through Friday. We simply ask that you select a consistent schedule and adhere to those hours. SolutionHealth is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, disability status, veteran status, or any other characteristic protected by law. #J-18808-Ljbffr