Authorization Denials Appeals Nurse

#LI-Remote Shriners Children’s is an organization that respects, supports, and values each other. Named as the 2025 best mid-sized employer by Forbes, we are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact. We foster a learning environment that values evidenced based practice, experience, innovation, and critical thinking. Our compassion, integrity, accountability, and resilience define us as leaders in pediatric specialty care for our children and their families. All employees are eligible for medical coverage on their first day! In addition, upon hire all employees are eligible for a 403(b) and Roth 403 (b) Retirement Saving Plan with matching contributions of up to 6% after one year of service. Employees in a FT or PT status (40+ hours per pay period) will also be eligible for paid time off, life insurance, short term and long-term disability and the Flexible Spending Account (FSA) plans and a Health Savings Account (HSA) if a High Deductible Health Plan (HDHP) is elected. Additional benefits available to FT and PT employees include tuition reimbursement, home & auto, hospitalization, critical illness, pet insurance and much more! Coverage is available to employees and their qualified dependents in accordance with the plans. Benefits may vary based on state law.

The Authorization Denials Appeals Nurse is responsible for managing authorization denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The appeals nurse will analyze pre- and post-service authorization denials to determine if there is clinical justification to submit a request for retro-authorization. The Authorization Denials Appeals Nurse will serve as a clinical resource to the Central Authorization Unit and provide peer-to-peer reviews when the payer allows a nurse to participate in the process. The Authorization Appeals Nurse will write sound, compelling factual arguments for appealing authorization denials. The person in this position will be responsible for maintaining a detailed knowledge of Third-Party Payers’ and Governmental Payers’ clinical/medical necessity/authorization criteria and will be responsible for filing compliant appeals in accordance with third-party and governmental contracts.

Screens denials for possible reconsideration, peer to peer, or formal appeal. Investigates denials and root causes and tracks and reports trends to remediate issues and assist with internal process improvement. Prepares and submits appeals per payer guidelines Leverages clinical knowledge and standard procedures to ensure timely attention to denials as requested by PFS and assists in the research and application of regulatory policies to support administrative appeals. Communicates pertinent clinical information to Physicians, Medical Directors, and other members of SCMG, as indicated, regarding evaluation of payer determinations. May educate other departments regarding payer changes and denial/appeal process. Understands clinically complex medical situations and communicates appropriately with insurers as needed. Utilizes working knowledge of basic coding guidelines for medical necessity and insurance authorization escalations and/or denials. Maintains expert knowledge of how to navigate payer websites to validate insurance eligibility and authorization requirements, as well as determine the method in which a payer requires appeal submission. This is not an all-inclusive list of this job’s responsibilities. The incumbent may be required to perform other related duties and participate in special projects as assigned.