Clinical Appeal Nurse

Advocate Health • Charlotte, NC

1d • $38 - $57

About The Position

The Clinical Appeal Nurse uses clinical nursing expertise to evaluate denied claims, determine whether cases qualify for appeal, and manage appeals through resolution or exhaustion of available options. The role applies clinical and regulatory knowledge, established level-of-care criteria, medical-necessity documentation, and patient-status requirements to concurrent and retrospective reviews. It also researches payer and government requirements, prepares clinical appeal materials and medical-necessity letters, and maintains denial status documentation.

The nurse helps reduce third-party payer denials by identifying denial trends and working with internal departments and physician advisors on education and corrective action. The position also provides clinical support during operational reviews with third-party payers and helps document issues that prevent claim payment.

This is a full-time position scheduled for 40 hours per week. The role requires an NC compact state license; external hires must apply for an Illinois state license after a 90-day probationary period. Travel is required, and the position operates in a normal office environment.

Requirements

• Registered Nurse (RN) licensure.
• Bachelor's degree in Nursing.
• NC compact state license; external hires must apply for an Illinois state license after the 90-day probationary period.
• Experience with current CPT and HCPCS coding nomenclature and rules, ICD-10 coding conventions, and clinical documentation standards.
• Previous clinical or technical documentation and chart-review experience, with understanding of medical terminology.
• Knowledge of appeal criteria and federal, state, and local regulations.
• Experience with level-of-care criteria such as MCG and/or InterQual and with clinical documentation standards.
• Excellent critical-thinking and analytical skills, with high attention to detail.
• Ability to meet deadlines while working independently in a fast-paced environment.
• Ability to take initiative and work collaboratively with others.
• Strong computer skills, including high proficiency with Microsoft Office Suite.
• Excellent writing skills needed to facilitate the advanced appeal process.
• Ability to travel and exposure to weather and road conditions.
• Ability to operate all equipment necessary to perform the job.

Responsibilities

• Assess denied claims and determine whether each case is eligible for appeal using clinical and regulatory knowledge, level-of-care criteria, medical-necessity documentation, and patient-status orders.
• Review medical records and write appeals using industry guidelines, Medicare Benefit Policy Manual guidelines, national and local coverage determinations, best-practice standards, and clinical judgment.
• Research denied claims and apply payer and government rules, regulations, and third-party requirements to determine appeal eligibility.
• Conduct concurrent and retrospective clinical reviews using pre-established criteria approved by the Medical Staff.
• Continue the appeal process until the case is overturned, appeal options are exhausted, or a decision is made to discontinue the process; document denial status in denial software.
• Prepare denials for clinical appeal processing involving authorization, coding, level of care, or length of stay, and write medical-necessity appeal letters.
• Prioritize appeals according to filing deadlines established by payer contracts or governmental bodies.
• Secure medical documentation required or requested by insurance carriers to support appeals.
• Identify denial trends and collaborate with the business office, pre-service, case management, utilization management, contracting, audit, and physician advisors to support education or corrective action related to admission, charging, coding, documentation, patient status, or billing.
• Provide clinical expertise to help resolve third-party payer issues during operational review meetings.
• Assist in documenting issues and trends that prevent payment of claims for services.

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.
• Competitive compensation, premium pay for eligible positions, incentive pay for select positions, and opportunity for annual performance-based increases.
• Career-development and well-being programs.

What This Job Offers

• Job Type: Full-time