Appeals Nurse Coordinator

Xsolis; United States; On-site; USD 75,000 - 95,000; Full time

Benefits offered by this job

Medical coverage

401K match

PTO

Parental leave

HSA/FSA

Education reimbursement

EAP & mental health

Job summary

Xsolis is seeking an Appeals Nurse Coordinator II in the United States. This full-time role reviews medical necessity, DRG assignment, and denial/appeal activities. You will leverage AI-enabled tools and collaborate with payers and clients to support clinical reviews and documentation integrity.

The ideal candidate has an active nursing license, strong documentation and communication skills, and experience with ICD-10/DRG concepts. Travel to TN offices for training is required.

Qualifications

• Active RN or LPN license required.
• Clinical nursing experience required.
• Experience reviewing and interpreting medical records.
• Strong written and verbal communication skills essential.
• Ability to organize, prioritize, and manage multiple cases.
• Familiarity with ICD-10, DRG concepts.
• Familiarity with AI-enabled tools in clinical review.
• Proficiency with Microsoft Word and Excel.

Responsibilities

• Perform clinical reviews per managed care, payer, and CMS requirements.
• Assist with determining appropriate level of care and medical necessity.
• Review clinical documentation related to ICD-10 coding and DRG assignment.
• Support denial management and prepare appeal correspondence.
• Evaluate documentation for care, coding, and reimbursement needs.
• Provide feedback on care level, LOS, outcomes, and documentation.
• Identify needs for additional clinical-record documentation.
• Apply clinical guidelines in case reviews.
• Use AI-enabled tools to aid research and workflows.
• Research payer policies and regulatory requirements as needed.
• Communicate with payers/clients regarding determinations and rationale.
• Maintain knowledge of regulatory changes and industry standards.
• Document findings and trends for client needs.
• Perform other duties as assigned.

Skills

Active RN or LPN license

Clinical nursing experience

Medical record review

Strong communication

Case management

ICD-10/DRG familiarity

AI-enabled tools familiarity

MS Word & Excel

Tools

Epic

Cerner

Meditech

Job description

Redefining Healthcare with AI Xsolis is an AI-driven technology company reducing administrative waste in healthcare by enabling smarter collaboration between providers and payers. Since 2013, our vision has been to create a frictionless healthcare system.

Redefining Healthcare with AI Xsolis is an AI-driven technology company reducing administrative waste in healthcare by enabling smarter collaboration between providers and payers. Since 2013, our vision has been to create a frictionless healthcare system. We are proudly headquartered in Franklin, TN - one of the nation's fastest-growing hubs for healthcare innovation - we are at the heart of a thriving ecosystem of health systems, payers, and technology leaders. Our flagship product, Dragonfly®, is the first and only AI-driven platform to continuously assign real-time predictive scores for medical necessity. Dragonfly has delivered proven results across 600+ hospital, health system, and health plan clients and earned repeated industry recognition. With recognition on the Inc. 5000 and Deloitte Technology Fast 500 lists, Xsolis is also one of the fastest-growing privately-held companies in the country and across North America, and we're looking for talented people to grow with us.

Position Summary Details The Appeals Nurse Coordinator II provides concurrent review and appeals support for XSOLIS clients. This role reviews clinical documentation, supports denial and appeal activities, and evaluates medical necessity, level of care, and documentation related to ICD-10 coding and DRG assignment.

The ideal candidate will have a clinical nursing background and familiarity with utilization management, denials and appeals, clinical documentation integrity, DRG clinical validation, payer requirements, applicable state and federal regulations, and AI-enabled tools used to support clinical review and healthcare workflows.

Essential Duties & Responsibilities The essential functions include, but are not limited to the following:

• Perform clinical reviews in accordance with managed care, payer, and CMS requirements.
• Assist with determining appropriate level of care and medical necessity.
• Review clinical documentation related to ICD-10 coding and DRG assignment.
• Support denial management and preparation of appeal correspondence.
• Evaluate whether documentation supports the care provided and applicable coding or reimbursement requirements.
• Provide feedback to internal and external partners regarding level of care, length of stay, case outcomes, and clinical documentation.
• Identify opportunities for clarification or additional medical-record documentation.
• Apply relevant clinical and industry guidelines when reviewing cases.
• Review cases using applicable utilization management and clinical documentation resources.
• Use available technology, including AI-enabled tools, to support research, documentation review, workflow efficiency, and case analysis as appropriate.
• Research payer policies, contracts, and regulatory requirements as needed.
• Communicate with payers and clients regarding claim determinations and appeal rationale.
• Maintain current knowledge of regulatory changes, clinical practice, payer requirements, healthcare technology, and industry standards.
• Document findings and identify trends or other information relevant to client needs.
• Perform other related duties as assigned.

Minimum Qualifications (Knowledge, Skills, And Abilities)

• Active RN or LPN license.
• Clinical nursing experience.
• Experience reviewing and interpreting medical records.
• Strong written and verbal communication skills.
• Ability to organize, prioritize, and manage multiple cases.
• Familiarity with healthcare reimbursement, medical necessity, utilization management, denials and appeals, clinical documentation, or related functions.
• Familiarity with ICD-10, DRG concepts, and electronic medical records.
• Familiarity with AI-enabled tools or other healthcare technology used to support clinical, documentation, research, or administrative workflows.
• Proficiency with common business applications, including Microsoft Word and Excel.

Other

• Experience in utilization review, case management, auditing, denials and appeals, CDI, or DRG clinical validation.
• Familiarity with InterQual, MCG, CMS medical necessity requirements, and the Two-Midnight Rule.
• Familiarity with CDI resources and guidance, including ACDIS and similar industry resources.
• Experience with electronic medical record systems such as Epic, Cerner, or Meditech.
• Experience using AI-enabled tools in clinical review, documentation, research, appeals, or related healthcare workflows.
• Case management, coding, utilization review, or CDI certification.

Supervisory Responsibilities This role does not include supervisory responsibilities and is an individual contributor role.

Working Environment And Travel Requirements

• Work is typically in a normal office administrative environment involving minimal exposure to physical risks.
• Position requires little to moderate physical activity. Mostly sedentary work exerting up to 10 pounds of force occasionally or a negligible amount of force to lift, carry, push, pull, or otherwise move objects. Work involves sitting most of the time, but may involve walking or standing for brief periods of time. No significant stooping is usually required.
• This role requires travel to our home offices in TN for training.

Physical Demands & Work Environment The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions. In any role at Xsolis, it's a chance to make a complex healthcare system a little more efficient alongside a team that's passionate, fast-moving, and genuinely invested in your success. Your contributions will shape both our product and our culture.

Full-time Employees’ Total Rewards Package Include

• Medical/Dental/Vision insurance
• 401K company match
• Flexible Paid Time Off
• Paid parental leave
• HSA/FSA options
• Educational reimbursement program
• Employer-paid EAP & Mental Health services

Xsolis is proud to be an equal opportunity employer. We celebrate diversity and are committed to building an inclusive environment for all. We encourage candidates of every background to apply.

All candidates must successfully pass a background check andfall under the same security role, which includes access to sensitive information, including proprietary data and PHI.

Work Authorization Notice: Please note that we do not provide visa sponsorship or immigration support for this position. Applicants must already be authorized to work in the United States on a full-time, permanent basis without the need for current or future sponsorship.

All official communications from our recruitment team will only come from @xsolis.com. Verify open roles at https://www.xsolis.com/about/careers. For information regarding how we collect, use, and protect applicant personal information, please review our CCPA Privacy Notice for Job Applicants.