Appeals Specialist ( Required to live locally)

RegalCare; Holyoke (MA); Hybrid; USD 70,000 - 90,000; Full time

Job summary

RegalCare in Massachusetts is seeking an Appeals Specialist (LPN/RN/therapist) to lead clinical appeals, audit management, and medical records oversight across our facility network. You will review denials, assemble clinical evidence, and craft persuasive appeals to protect reimbursement while ensuring documentation compliance.

Work closely with multidisciplinary teams to educate staff on proper documentation habits, coordinate internal and external audits, and maintain a centralized tracking

Qualifications

• Active Massachusetts RN/LPN or Therapist licensure.
• 2–3 years clinical experience in skilled nursing, LTC, or healthcare administration.
• Knowledge of Medicare Part A/B, Medicaid, and managed care guidelines.
• Strong written and verbal communication; proficient with EHRs.

Responsibilities

• Lead clinical appeals by reviewing denials and drafting compelling appeals.
• Coordinate internal and external audits and ensure timely responses.
• Audit medical records for completeness, clinical necessity, and coding accuracy.
• Collaborate with care teams to educate on documentation to prevent denials.
• Maintain a centralized tracking system for appeals and financial recovery metrics.

Skills

Written communication

Verbal communication

Analytical skills

EHR systems

Job description

Appeals Specialist (LPN, RN, or Therapist)

Location: Massachusetts (RegalCare Facility network / Hybrid-Remote options available)

Position Type: Full-Time

Role Overview

RegalCare is seeking a detail-driven Appeals Specialist to lead our clinical appeals, audit management, and medical records oversight. In this vital role, you will review clinical denials, construct compelling clinical arguments, and interface with payers to protect reimbursement and ensure documentation compliance across our Massachusetts facilities.

Key Responsibilities

• Appeals Management: Analyze insurance denials, Medicare/Medicaid rejections, and managed care disputes. Gather clinical evidence and draft comprehensive appeals to overturn adverse determinations.
• Audit Oversight: Coordinate internal and external clinical audits, ensuring timely responses, accurate data compilation, and adherence to regulatory standards.
• Medical Records Integrity: Partner with facility Director of Nursing, MDS Coordinators, and therapy teams to audit medical records for completeness, clinical necessity, and coding accuracy.
• Clinical Collaboration: Work directly with multidisciplinary care teams (LPNs, RNs, PT/OT/ST Therapists) to educate staff on proper documentation habits that prevent future denials.
• Tracking & Reporting: Maintain a centralized tracking system for all pending appeals, audit outcomes, and financial recovery metrics, presenting regular updates to leadership.

Qualifications & Requirements

• Licensure: Active, unencumbered Massachusetts license as a Registered Nurse (RN), Licensed Practical Nurse (LPN), or Physical/Occupational/Speech Therapist.
• Experience: Minimum 2-3 years of clinical experience in skilled nursing, long-term care, or healthcare administration.
• Expertise: Demonstrated working knowledge of Medicare Part A/B, Medicaid, Managed Care guidelines, and clinical reimbursement rules.
• Skills: Exceptional written and verbal communication skills, strong analytical capability, and proficiency in electronic health record (EHR) systems.