Clinical Appeal Nurse

Department 10341 Enterprise Revenue Cycle - Revenue Recovery Audit

Department 10341 Enterprise Revenue Cycle - Revenue Recovery Audit

Status Full time

Benefits Eligible Yes

Hours Per Week 40

Schedule Details/Additional Information Must have NC compact state license and apply for IL state license after 90-day probationary period if external hire

Pay Range $38.20 - $57.30

Major Responsibilities

• Utilize clinical nursing expertise to assess denied claims for timely evaluation and determine eligibility for appeal using established clinical level-of-care criteria, documentation of medical necessity, and appropriateness of status order.
• In-depth knowledge of CMS regulations and other federal, state, and payer-specific compliance requirements and government audit protocols.
• Utilize industry guidelines, Medicare Benefit Policy Manual, national and local coverage determinations, and best practice standards, applying sound clinical judgment in reviewing medical records and completing appeals.
• Research and analyze denied claims using payer and government rules and regulations to determine appeal eligibility based on third-party requirements.
• Leverage AI-driven tools and technologies to enhance appeal writing efficiency, ensure accuracy, and support data-driven decision-making in denial management.
• Continue the appeal process until the case is overturned, appeal options are exhausted, or a decision is made to discontinue, ensuring ongoing documentation of denial status in denial software.
• Prepare clinical appeals for authorization, coding, level of care, medical necessity, and/or length of stay denials.
• Prioritize appeals according to filing limitations established by individual payer contracts and/or governmental bodies. Secure required medical documentation from providers or request from insurance carriers to support the appeal process.
• Work to minimize payer denials by identifying trends and partnering with departments such as Denial Avoidance, Billing Operations, Pre-Service, Case Management, Utilization Management, Contracting, Audit, other Revenue Cycle teams, and physician advisors to provide education and corrective action for errors related to admission, charging, coding, documentation, patient status, or billing.
• Communicate denial issues, patterns and barriers impacting claim payment to the Clinical Appeal RN Lead, to present during payer meetings to facilitate resolution as applicable.
• Escalate to Revenue Recovery leadership to coordinate cross-functional teams in implementing denial prevention strategies and enhancing financial sustainability.

Licensure

• Current, unrestricted RN license.

Education/Experience Required

• Bachelor’s Degree in Nursing or Associate Degree Nursing with a Bachelor of Science Degree
• Minimum 3 years clinical experience in acute care. Preferred experience in utilization review, case management, denials/appeals/government audits, or revenue cycle.

Knowledge, Skills & Abilities Required

• Excellent critical thinking and analytical skills, with a high attention to detail.
• Ability to meet deadlines while independently working in a fast-paced environment.
• Proficiency with Microsoft Office and Epic; experience with denial management software.
• Experience with CPT and HCPCS coding nomenclature, ICD-10 coding conventions, clinical documentation standards, and reimbursement methodologies.
• Previous clinical/technical documentation and chart review experience along with understanding of medical terminology.
• Knowledge of appeals criteria and understanding of federal, state and local regulations.
• Experience with level of care criteria (MCG and/or InterQual), Medicare Guidelines - NCD (National Coverage Determination) and LCD (Local Coverage Determination), and clinical documentation standards.
• Ability to take initiative and work collaboratively with others.
• Strong computer skills, including high proficiency with Microsoft Office Suite.
• Excellent writing skills are necessary to facilitate the advanced appeal process.

Physical Requirements And Working Conditions

Fully remote work environment

Our CommitmenttoYou

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

Compensation

• Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
• Premium pay such as shift, on call, and more based on a teammate's job
• Incentive pay for select positions
• Opportunity for annual increases based on performance

Benefits And More

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, andShort- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

Note: Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.); please ask a Recruiter for more information during an interview.

About Advocate Health

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.

The Clinical Appeal Nurse utilizes clinical nursing expertise and strong knowledge of denial management and regulatory requirements to minimize financial risk associated with post-service inpatient level-of-care and outpatient denials, and adverse audit decisions. This role ensures timely and effective appeal of denied claims, applying evidence-based criteria, regulatory guidelines, and payer-specific requirements. The nurse collaborates with physicians, utilization management, revenue cycle teams, coding, contracting, government agencies, and payer representatives to overturn inappropriate denials and improve denial prevention strategies.