Appeals Nurse Coordinator

Xsolis, Inc

About The Position

The Appeals Nurse Coordinator II provides concurrent review and appeals support for XSOLIS clients. The role reviews clinical documentation, supports denial and appeal activities, and evaluates medical necessity, level of care, and documentation related to ICD-10 coding and DRG assignment. The ideal candidate has a clinical nursing background and familiarity with utilization management, denials and appeals, clinical documentation integrity, DRG clinical validation, payer requirements, applicable state and federal regulations, and AI-enabled tools used to support clinical review and healthcare workflows. This is an individual contributor position with no supervisory responsibilities. Work is typically performed in a normal office administrative environment with minimal exposure to physical risks. The role requires little to moderate physical activity and travel to XSOLIS home offices in Tennessee for training.

Requirements

Active RN or LPN license.
Clinical nursing experience.
Experience reviewing and interpreting medical records.
Strong written and verbal communication skills.
Ability to organize, prioritize, and manage multiple cases.
Familiarity with healthcare reimbursement, medical necessity, utilization management, denials and appeals, clinical documentation, or related functions.
Familiarity with ICD-10, DRG concepts, and electronic medical records.
Familiarity with AI-enabled tools or other healthcare technology used to support clinical, documentation, research, or administrative workflows.
Proficiency with common business applications, including Microsoft Word and Excel.

Nice To Haves

Experience in utilization review, case management, auditing, denials and appeals, CDI, or DRG clinical validation.
Familiarity with InterQual, MCG, CMS medical necessity requirements, and the Two-Midnight Rule.
Familiarity with CDI resources and guidance, including ACDIS and similar industry resources.
Experience with electronic medical record systems such as Epic, Cerner, or Meditech.
Experience using AI-enabled tools in clinical review, documentation, research, appeals, or related healthcare workflows.
Case management, coding, utilization review, or CDI certification.

Responsibilities

Perform clinical reviews in accordance with managed care, payer, and CMS requirements.
Assist with determining appropriate level of care and medical necessity.
Review clinical documentation related to ICD-10 coding and DRG assignment.
Support denial management and preparation of appeal correspondence.
Evaluate whether documentation supports the care provided and applicable coding or reimbursement requirements.
Provide feedback to internal and external partners regarding level of care, length of stay, case outcomes, and clinical documentation.
Identify opportunities for clarification or additional medical-record documentation.
Apply relevant clinical and industry guidelines when reviewing cases.
Review cases using applicable utilization management and clinical documentation resources.
Use available technology, including AI-enabled tools, to support research, documentation review, workflow efficiency, and case analysis as appropriate.
Research payer policies, contracts, and regulatory requirements as needed.
Communicate with payers and clients regarding claim determinations and appeal rationale.
Maintain current knowledge of regulatory changes, clinical practice, payer requirements, healthcare technology, and industry standards.
Document findings and identify trends or other information relevant to client needs.
Perform other related duties as assigned.