Hospital Appeal Nurse

You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.


Job Summary


Our client is seeking a Hospitalist to handle denial reviews and analysis, appeal development, and ensure compliance with payer regulations. The primary goal is to enhance documentation accuracy and support AI-driven denials/appeals initiatives.


Key Responsibilities

• Review payer denials and analyze medical records against criteria such as MCG Guidelines and InterQual Criteria.
• Write strong, evidence-based appeal letters and prepare first-level, second-level, and external appeals.
• Partner with physician advisors for complex or high-dollar denials and assist with Peer-to-Peer preparations.
• Evaluate the completeness and accuracy of medical records and recommend improvements.
• Stay current with CMS rules and commercial payer policies, ensuring appeals meet filing requirements.
• Track appeal outcomes and support denial prevention initiatives with actionable insights.
• Review charts, medications, diagnoses, and clinical criteria to support admissions and appeals.

Qualifications

• 3 - 5+ years of clinical experience, preferably in acute care.
• Experience in Utilization Review, Case Management, Clinical Documentation Improvement, and Medical Record Audits.
• Strong clinical assessment and critical thinking skills.
• Advanced writing and documentation skills.
• Knowledge of medical necessity criteria (MCG/InterQual), DRG/APR-DRG reimbursement, and payer policies.
• Preferred experience in Utilization Management, Utilization Review, and Clinical Auditing.
• EPIC experience is strongly preferred.

Benefits

• Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
• Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
• 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
• Short Term Disability Insurance.
• Term Life Insurance Plan.

Required Employment / Compliance Language


Medix is an equal opportunity employer. We are dedicated to providing a safe and inclusive environment for all employees.


* We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).


Medix Overview:


With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we're dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.


* As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient's residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.