Clinical Appeals Nurse

3 days ago


Angeles City, Central Luzon, Philippines Connext Global Solutions Inc Full time $60,000 - $120,000 per year

Job Description

The Clinical Appeals Nurse audits medical records for hospitals to address denials, defend charges, and support utilization reviews. They write detailed appeal letters, ensure regulatory compliance, and work across multiple systems to manage and resolve complex clinical cases.

Responsibilities:

  • Conduct comprehensive medical record audits to identify, defend, or validate charges using standardized criteria and payer guidelines.
  • Evaluate medical necessity and support appeals involving managed care reviews, RAC/CERT/ZPIC/SMRC audits, and avoidable length of stay.
  • Gather required documentation from clinicians, facilities, patients, and medical literature to support audit findings and appeals.
  • Draft detailed clinical and contractual appeal letters and manage multiple cases with timely, accurate documentation in client systems.

Qualifications and Requirements:

  • Minimum three years of clinical or relevant audit/appeals/utilization review/denials experience, including bedside nursing.
  • Strong background in Medicare/Medicaid regulations, medical records review, claims processing, or clinical case management.
  • Proficient in Microsoft Office and experienced in EMRs with the ability to navigate multiple systems.
  • Exceptional written and verbal communication skills with high attention to detail and accuracy.


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