Clinical Appeals Specialist RN - Remote

Overview

The Clinical Appeals Specialist RN is responsible for reviewing and appealing clinical claim denials and audit determinations for the hospital, utilizing clinical expertise to support the medical necessity of services billed.

In Short

• Review and resolve clinical claim denials and audit determinations.
• Apply clinical expertise to determine medical necessity of services billed.
• Develop and write appeal rationales supported by medical documentation.
• Interpret payer policies and guidelines for clinical rationale.
• Coordinate with Medical Directors for clarifications.
• Analyze trends from audits and present for process improvement.
• Collaborate with Care Management to align clinical criteria with payer guidelines.
• Participate in Audit and Denials Committee.
• Enhance clinical skills with current guidelines and regulations.
• Perform other duties as assigned.

Requirements

• Licensed as a Registered Nurse (RN) in Washington.
• Experience in clinical, health insurance, or case management.
• Strong written and verbal communication skills.
• Highly detail-oriented and organized.
• Ability to interpret regulatory guidance and payer policies.
• Decision-making capabilities regarding delegated responsibilities.
• Experience with payer audits and claim denials.

Benefits

• Medical, vision, and dental insurance.
• On-demand virtual health care.
• Health Savings Account and Flexible Spending Account.
• Life and disability insurance.
• Retirement plans with employer contribution.
• Tuition assistance for degrees.
• Paid Time Off/Vacation and paid holidays.
• Commuter benefits and free parking.
• Federal Public Service Loan Forgiveness program.
• Voluntary insurance options available.