RN Clinical Appeals Specialist

SolutionHealth • Manchester, NH

2d

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 develops appeal arguments grounded in clinical documentation and payer medical policies. The specialist works with clinical and revenue cycle teams to identify denial root causes and contributes to staff education and process improvements intended to reduce future denials and enhance revenue integrity.

The position reviews clinical denials, conducts medical record reviews, prepares clinical summaries and customized appeal letters, and manages appeals through all stages. It includes communicating with payer representatives, legal counsel, and other stakeholders; presenting appeals to Administrative Law Judges when appropriate; assisting billing and case management teams with high-risk or high-dollar accounts; applying national clinical guidelines; analyzing denial trends; assessing reimbursement risk; and ensuring appeal work is documented and completed on time. The specialist also participates in training and work groups, meets performance expectations, maintains required licensure or certification, protects confidential information, and performs other assigned duties.

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

Requirements

• Associate Degree in Nursing.
• Three or more years in medical coding or billing.
• Applicable RN license.
• 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.
• 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.
• Research and analytical skills for trending and analysis.
• Effective verbal and written communication skills for collaboration with peers, providers, leadership, and other 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.
• Critical thinking and root-cause analysis skills, with a growth mindset.
• Familiarity with technology and data tools, including Epic, Microsoft Excel, and coding, billing, and appeals software.
• Ability to develop and maintain effective relationships throughout the organization.
• Commitment to patient confidentiality, regulatory compliance, professional standards, and ethical behavior.
• Current permanent U.S. work authorization required.

Nice To Haves

• Bachelor of Science in Nursing preferred.
• Certified coding credentials such as CPC, CPC-H, CCS, CCS-P, RHIT, or RHIA.
• Experience with Epic Coding, HIM, and Revenue Integrity applications.

Responsibilities

• Review clinical denials and initiate appeals in accordance with internal guidelines and payer-specific requirements.
• Review medical records and prepare clinical summaries aligned with payer policies to support appeal submissions.
• 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 in reviewing high-risk or high-dollar accounts before claim submission.
• Analyze denial data to identify patterns and root causes and share insights 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, including 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 for assigned responsibilities.
• Maintain current certification and/or licensure as required by federal and state 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 and long-term disability insurance.
• 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