Clinical Appeals Registered Nurse - Fully Remote

A Clinical Appeals Registered Nurse (RN) is responsible for reviewing and analyzing clinical cases to determine the appropriateness of healthcare services provided to patients. They work with insurance companies, healthcare providers, and patients to resolve denied or disputed claims by evaluating clinical documentation and making evidence-based

Review denied insurance claims and clinical documentation to assess the validity of the denial. Work closely with healthcare providers and insurance companies to gather additional information or documentation needed for appeal. Ensure compliance with clinical guidelines, regulatory standards, and payer policies. Communicate effectively with patients, healthcare providers, and insurance representatives regarding the appeal process. Prepare and submit formal written appeals, including necessary clinical evidence to support the appeal. Analyze trends in claim denials and provide feedback to the healthcare provider or organization to improve future outcomes. Stay updated on industry regulations, payer policies, and clinical best practices to ensure accuracy in appeal submissions.