Clinical Appeals Writer

Job Overview The Clinical Appeals Nurse is responsible for creating a convincing and effective appeal based on clinical documentation, payer‑specific standards, and compliance with federal and state policies. The role handles clinical denial appeals and follow‑up, providing relevant denial information to departments to ensure that systems, processes, and effectiveness measures are created and implemented to resolve root‑cause issues and reduce/eliminate denials. The Clinical Appeals Nurse ensures that appeals are filed on time. Responsibilities Performs medical record reviews concurrently and/or retrospectively and can determine why cases are denied and whether an appeal is required Able to review clinical denials promptly and appropriately, utilizing clinical criteria sets such as InterQual® criteria (Acute, Procedures, etc.). If the clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medically necessary services denied for lack of authorization. Able to write an effective and efficient appeal based on clinical documentation and payer‑specific policies, and client‑specific instructions. Able to think critically and use clinical judgment in providing effective and well‑supported appeals. Maintains thorough and current knowledge in clinical expertise and stays relevant in the fast‑changing trends in healthcare, reimbursement methodologies, and utilization. Able to demonstrate basic patient accounting knowledge, i.e., UB04 claim form and Explanation of Benefits (“EOB”) components, adjustments, credits, debits, balance due, patient liability, etc. Able to read and understand medical abstract information from handwritten to typed medical records. Demonstrates proficiency in the utilization of electronic tools and competency in Microsoft Office. Able to observe specific payer guidelines for appeal submission and ensure compliance with law and regulations. Other tasks/functions that may be assigned by the company as per business requirement; these may change from time to time to reflect the changing requirements of your position and our business. Qualifications Education Graduate of BS in Nursing Strong writing and grammatical skills Above‑average written and verbal communication skills Certification / Licensure Must be a Registered Nurse Knowledge and Skills Demonstrates proficiency in the application of medical necessity criteria. Ability to conduct intensive research regarding State/Federal guidelines and other regulatory processes. Must have experience in writing appeals. Excellent communication skills in verbal and professional letter writing skills. Able to think critically. Ability to multitask. Ability to work with minimal supervision and able to work under pressure within the given timeframe. Benefits Temporary Work From Home Setup 30k Sign On Bonus #J-18808-Ljbffr