Clinical Appeal Nurse

Advocate Health and Hospitals Corporation•Charlotte, NC

1d•Remote

About The Position

The Clinical Appeal Nurse uses clinical nursing expertise to assess denied claims, determine appeal eligibility, and prepare appeals using clinical level-of-care criteria, medical-necessity documentation, status orders, and applicable payer and government requirements. The role reviews medical records and applies sound clinical judgment, CMS regulations, federal and state requirements, payer rules, government audit protocols, industry guidelines, Medicare coverage determinations, and best-practice standards. The nurse uses AI-driven tools to improve appeal-writing efficiency and accuracy and support data-driven denial-management decisions. The nurse manages eligible appeals through resolution, exhaustion of appeal options, or a decision to discontinue, while documenting denial status in denial software. The work includes prioritizing appeals by filing deadlines, obtaining necessary medical documentation, and collaborating with Revenue Cycle and clinical teams to identify denial trends, educate stakeholders, correct errors, and develop prevention strategies. This is a fully remote position.

Requirements

Current, unrestricted RN license.
Bachelor’s degree in Nursing, or an Associate Degree in Nursing with a Bachelor of Science degree.
Minimum 3 years of clinical experience in acute care.
NC compact state license; external hires must apply for an Illinois state license after the 90-day probationary period.
Excellent critical-thinking and analytical skills, with strong attention to detail.
Ability to meet deadlines while working independently in a fast-paced environment.
Proficiency with Microsoft Office and Epic; strong computer skills, including high proficiency with Microsoft Office Suite.
Experience with CPT and HCPCS coding nomenclature, ICD-10 coding conventions, clinical documentation standards, and reimbursement methodologies.
Clinical or technical documentation and chart-review experience, and understanding of medical terminology.
Knowledge of appeals criteria and federal, state, and local regulations.
Experience with level-of-care criteria such as MCG and/or InterQual, Medicare guidelines including NCD and LCD, and clinical documentation standards.
Ability to take initiative and work collaboratively with others.
Excellent writing skills to facilitate the advanced appeal process.

Nice To Haves

Experience in utilization review, case management, denials and appeals, government audits, or revenue cycle.
Experience with denial-management software.

Responsibilities

Assess denied claims promptly and determine appeal eligibility using clinical level-of-care criteria, medical-necessity documentation, and appropriateness of status orders.
Review medical records and apply CMS regulations, federal and state requirements, payer rules, government audit protocols, industry guidelines, Medicare coverage determinations, and best-practice standards.
Research denied claims and analyze payer and government rules to determine appeal eligibility.
Use AI-driven tools and technologies to improve appeal-writing efficiency, accuracy, and data-driven decision-making.
Manage the appeal process until a case is overturned, appeal options are exhausted, or a decision is made to discontinue; document denial status in denial software.
Prepare clinical appeals for authorization, coding, level-of-care, medical-necessity, and length-of-stay denials.
Prioritize appeals according to filing limitations established by payer contracts and government bodies.
Obtain required medical documentation from providers or request it from insurance carriers.
Identify denial trends and collaborate with Denial Avoidance, Billing Operations, Pre-Service, Case Management, Utilization Management, Contracting, Audit, Revenue Cycle teams, and physician advisors on education and corrective action.
Communicate denial issues, patterns, and payment barriers to the Clinical Appeal RN Lead for presentation during payer meetings, as applicable.
Escalate issues to Revenue Recovery leadership to coordinate cross-functional denial-prevention strategies and support financial sustainability.

Benefits

Paid time off programs.
Medical, dental, vision, life, and short- and long-term disability benefits.
Flexible Spending Accounts for eligible health-care and dependent-care expenses.
Adoption assistance and paid parental leave.
Defined-contribution retirement plans with employer match and other financial-wellness programs.
Educational Assistance Program.
Career-development programs.
Potential premium pay, including shift and on-call pay, based on the teammate’s position.
Incentive pay for select positions.
Opportunity for annual increases based on performance.