Clinical Appeals Nurse

Elevate Patient Financial Solutions℠ is a trusted partner who delivers superior RCM solutions to hospitals, health systems, and health providers nationwide. For more than 40 years, we've been developing and continually refining our best-in-class services and innovative, specialized technology to address the most complex challenges of the revenue cycle. We've carefully built teams with unmatched industry experience and service-specific expertise, and our commitment is to deliver on our promises, seek continuous improvement, and the pursuit of excellence to deliver results for our clients. Our services include Eligibility & Disability, Self-Pay, Third Party Liability, Workers' Compensation, Veterans Administration, COB Denials, Out-of-State Eligibility, and A/R Services, including A/R billing and insurance follow up, legacy conversions and project-specific aged A/R work down. With in-depth, state-specific knowledge and a coast-to-coast presence, ElevatePFS℠ delivers exceptional performance and an unmatched client experience.

Elevate Patient Financial Solutions has an exciting career opportunity available as a Clinical Appeals Nurse. This position will be remote based. The Full Time schedule for this role will be 8AM-4:30PM, Monday-Friday. Job Summary: The Clinical Appeals Nurse is the liaison and point of contact for clinical denials and appeals that are received after claim submission. Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or level of care.

Use their clinical knowledge, experience, and advanced critical thinking to ensure accuracy and integrity of the full life cycle of medical necessity denial determinations is properly administered. Evaluate clinical appeal letter correspondence for content, clarity, accuracy, and consistency. Package & send appeal and grievance information to the payors, monitors for the outcome of appeal and takes action accordingly (notify the provider and member as per delegation agreement), track all appeal information. Actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials. Participate in the review of audit findings as needed. Regular and timely attendance. Other duties as assigned.