Clinical Appeals Specialist RN - Revenue Integrity - Remote

Overview

The Clinical Appeals Specialist RN is responsible for reviewing and appealing clinical claim denials and audit determinations for hospitals, utilizing clinical expertise to interpret documentation and write appeals based on payer-specific guidelines.

In Short

• Review and resolve clinical claim denials.
• Apply clinical expertise to assess medical necessity.
• Write appeal rationales supported by medical documentation.
• Interpret payer policies and guidelines.
• Coordinate with Medical Directors on clinical determinations.
• Analyze audit trends and assist in process improvement.
• Collaborate with Care Management on clinical criteria alignment.
• Participate in Audit & Denials Committee.
• Maintain clinical skills and stay updated with guidelines.
• Perform additional duties as assigned.

Requirements

• Bachelor’s degree in Nursing or related field.
• 5 years of clinical experience, including 3 in utilization review.
• Experience with payer audits and claim denials.
• Licensed as a Registered Nurse (RN) in Washington.
• Knowledge of MCG, InterQual, or similar tools.
• Strong written and verbal communication skills.
• Attention to detail.
• Ability to interpret regulatory guidance and payer policies.

Benefits

• Medical, vision, and dental insurance.
• On-demand virtual healthcare.
• Health Savings Account.
• Flexible Spending Account.
• Life and disability insurance.
• Retirement plans with employer contributions.
• Tuition assistance for degrees.
• Paid Time Off/Vacation.
• Paid holidays.
• Commuter benefits.