RN Clinical Appeals Specialist

SolutionHealth • Manchester, NH

3d

About The Position

The Nurse Appeals Specialist evaluates clinical documentation to support the resolution and prevention of payer denials. The role examines denials involving billing accuracy, medical necessity, coding, and other key modifiers, and prepares appeal arguments based on clinical documentation and payer medical policies. The specialist collaborates with clinical and revenue cycle teams to identify denial root causes and contributes to staff education and process improvements that reduce future denials and enhance revenue integrity.

The position includes reviewing medical records, drafting appeal letters, managing appeals through all stages, communicating with payer representatives and other stakeholders, and presenting appeals to Administrative Law Judges when appropriate. It also supports pre-billing reviews of high-risk or high-dollar accounts, denial data analysis, reimbursement risk assessment, and timely, compliant documentation of appeal activities. The specialist participates in training and organizational work groups, maintains required licensure and certification, and performs other duties as assigned.

The schedule is eight hours per day, Monday through Friday, with work hours selected consistently within 7:00 a.m. to 6:00 p.m.

Requirements

• Associate Degree in Nursing.
• Three or more years in medical coding or billing.
• Applicable RN license.
• Certified coding credential such as CPC, CPC-H, CCS, CCS-P, RHIT, or RHIA.
• Three to five or more years of auditing and coding experience.
• Experience with medical chart review.
• Thorough knowledge of ICD-10-CM, CPT, DRG methodologies, and regulatory requirements associated with coding and DRG assignment.
• Knowledge of medical terminology, payer rules and regulations, CDM guidelines, billing issues, reimbursements, and advanced nursing principles.
• Experience with Epic Coding, HIM, and Revenue Integrity applications.
• Familiarity with Microsoft Office, including Word, PowerPoint, and Excel.
• Ability to review and analyze coding, billing, and medical-record documentation issues.
• Ability to work independently within standard practices and procedures and refer questions or issues to a supervisor.
• Time-management and project-management skills to handle large workloads.
• High attention to detail and commitment to accuracy, data integrity, and quality improvement.
• Strong research and analytical skills for trending and analysis.
• Effective verbal and written communication skills for collaboration with peers, providers, leadership, and hospital personnel.
• Ability to receive and apply feedback to improve quality and productivity.
• Flexibility and resilience to adapt to organizational change, shifting priorities, and evolving healthcare regulations.
• Ability to use technology and data tools, including Epic, Microsoft Excel, and coding, billing, and appeals software.
• Ability to develop and maintain effective organizational relationships to support operational goals and outcomes.
• Commitment to patient confidentiality, regulatory compliance, professional standards, and ethical behavior.
• Current permanent U.S. work authorization.

Nice To Haves

• Bachelor of Science in Nursing.

Responsibilities

• Review clinical denials and initiate appeals according to internal guidelines and payer-specific requirements.
• Review medical records and prepare clinical summaries for appeals, ensuring alignment with payer policies.
• Communicate with payer representatives, legal counsel, and other stakeholders throughout the appeal process; present appeals to Administrative Law Judges when appropriate.
• Monitor appeals through all stages, determine next steps, and ensure timely resolution or escalation to the highest level of review.
• Assist billing and case management teams with reviews of high-risk or high-dollar accounts before claim submission.
• Analyze denial data to identify patterns and root causes and share findings with Revenue Cycle leadership to inform process improvements.
• Draft customized appeal letters based on denial rationale and clinical documentation, ensuring clarity, accuracy, and compliance with payer guidelines.
• Apply national clinical guidelines, such as InterQual and Milliman Clinical Guidelines, to determine appropriate status and support appeal arguments.
• Assess reimbursement risk based on payer interactions and escalate complex or recurring issues to management with supporting data.
• Document appeal activities and complete them within required timeframes, coordinating internal and external resources as needed.
• Participate in ongoing training on system updates, policy changes, and best practices in coding, billing, and denial management.
• Meet or exceed established key performance indicators.
• Maintain current certification and/or licensure as required by regulations and organizational policies.
• Understand and carry out organizational policies and procedures; maintain confidentiality of employee, legal, client/patient, budget, and company matters.
• Participate in Elliot Health System work groups and in-services as appropriate.
• Learn new software programs quickly and independently.
• Perform other duties as assigned.

Benefits

• Health, dental, prescription, and vision coverage for full-time and part-time employees.
• Short-term disability and long-term disability coverage.
• Life insurance.
• Pet insurance.
• Tuition reimbursement.
• Nursing Student Loan Paydown Program.
• 403(b) retirement savings plans.
• Continuous earned time accrual.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree