Clinical Denials Appeals

3-5 Years

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Early Applicant

Job Description

Job description:

Key Responsibilities:

Denials and Appeals Management:

Review and evaluate denied claims, including payer policies and clinical documentation
Submit retro-authorizations in response to authorization denials
Conduct medical necessity reviews and prepare supporting clinical summaries
Write and submit detailed, well-supported appeals based on clinical documentation and payer guidelines
Track, document, and follow up on all appeals through resolution
Maintain accurate and timely communication with payers and internal stakeholders
Perform research to support appeals and stay updated on payer policies and best practices

Tracking, Reporting, and Trends:

Compliance and Continuous Improvement:

Qualifications:

Required:

At least 1 year of clinical appeals writing experience
3–5 years of acute care clinical experience in a hospital setting (2–3 years if ICU)
Bachelor of Science in Nursing (BSN)
Active PHRN or USRN license
Strong knowledge of U.S. healthcare systems, insurance regulations, and RCM processes
Proficiency in InterQual or MCG clinical guidelines
Experience with EMR systems such as Epic, Cerner, or Meditech
Excellent verbal and written English communication skills (minimum CEFR B2)