RN Clinical Appeals Specialist - Remote

Overview

The RN Clinical Appeals Specialist at Ensemble Health Partners plays a crucial role in managing clinically related claim denials and ensuring compliance with regulatory requirements while working collaboratively with various departments.

In Short

• Manage appeals for clinically related claim denials.
• Contact insurance plans to determine reasons for claim denials.
• Analyze claims and prepare necessary appeal materials.
• Gather additional medical documentation and resubmit claims.
• Act as a liaison between healthcare providers for documentation clarification.
• Work closely with departments like Case Management and HIM.
• Ensure timely communication of denial trends and outcomes.
• Meet regulatory compliance requirements.
• Participate in professional development and obtain certifications.
• Contribute to a culture of innovation and exceptional client experiences.

Requirements

• Current unrestricted nursing license (LPN or RN).
• CRCR or other approved certification required within 9 months of hire.
• 1 to 3 years of relevant experience preferred.
• Associate's Degree or equivalent experience required.
• Proficient in Microsoft Suite.
• Experience in hospital operations and medical record reviews.
• Strong analytical and communication skills.
• Ability to work collaboratively across departments.
• Commitment to customer obsession and innovation.
• Willingness to embrace new ideas and strive for excellence.

Benefits

• Bonus incentives and paid certifications.
• Tuition reimbursement for professional development.
• Comprehensive benefits package.
• Career advancement opportunities.
• Recognition programs for outstanding performance.
• Support for physical, emotional, and financial health.
• Collaborative and innovative work culture.
• Flexibility in work-life balance.
• Opportunity to work with a leading healthcare organization.
• Inclusive and diverse workplace environment.