Clinical Appeals Nurse

Founded in 2002, Health Business Solutions (HBiZ) is a high-impact, transitional outsourcing firm that provides near-term relief to overturn denied claims and accelerate cash while concurrently working with providers and health systems to address Revenue Cycle under-performance.

Clinical Appeals Nurse (RN) Status: Exempt Location: Remote Department: Clinical Appeals Reports To: Director of Clinical Appeals Position Overview: The Clinical Appeals Nurse supports HBiz’s revenue cycle operations by reviewing denied claims for clinical accuracy and medical necessity, developing evidence-based appeal strategies, and drafting payer-ready appeal documentation. This role plays a critical part in overturning denials, improving reimbursement outcomes, and ensuring compliance with payer policies and clinical standards.

Review medical records and payer denial rationale to determine appeal opportunities Assess medical necessity using clinical guidelines, payer policies, and regulatory standards Draft clear, concise, and evidence-based appeal letters for multiple levels of appeal Collaborate with coding, CDI, denial recovery, and operations teams to strengthen appeal strategy Identify documentation gaps and recommend improvements to reduce future denials Support peer-to-peer review preparation and provide clinical insight when needed Track appeal outcomes and contribute to reporting on overturn rates and trends Maintain compliance with HIPAA, payer requirements, and client confidentiality standards Participate in process improvement initiatives to enhance appeal success and efficiency