UM Appeals Nurse

Employee is expected to cheerfully and enthusiastically carry out tasks and responsibilities of the job, including but not limited to, high quality professional patient care, thorough and accurate documentation, a willingness to work closely with physicians, administrators, coworkers, and supervisors. Prompt assistance to other units/ departments is expected as well as prompt assistance within the employee’s own unit/ department. By following the guidelines outlined in this job description, high quality patient care will be assured, and the continued success of Curative.

Interacts with providers, facilities and their staff regarding appeals and complaints and ensuring all assigned work is completed by the end of each workday. Review denied medical claims and services to determine the validity of the denial based on clinical guidelines, medical necessity, and payer policies Draft comprehensive appeal letters and clinical justifications to support overturning denied claims, ensuring accuracy, compliance, and timeliness Analyze patient medical records, treatment plans, and diagnostic results to assess the appropriateness and necessity of care Communicate with physicians, healthcare providers, and insurance representatives to clarify medical information and support the appeals process Ensure all appeals, reviews, and communications are documented accurately in accordance with regulatory and organizational policies Stay up-to-date with insurance payer guidelines, clinical protocols, and regulatory requirements (e.g., CMS, NCQA, URAC) Monitor and report on appeal status and success rates; identify trends and recommend process improvements to reduce denials Provide clinical insight to case managers, utilization review staff, and billing departments to prevent future denials Protect patient confidentiality and ensure all appeal activities follow HIPAA and other privacy laws Contribute to initiatives aimed at enhancing the efficiency and effectiveness of the appeals process Participates in special projects as required Researches complex cases as needed under the direction of the Manager or Medical Director Performs other duties as assigned, not limited to, but including availability to work occasional weekends depending on business needs