Appeals Specialist ( Required to live locally)

RegalCare at Greenfield; Holyoke (MA); Hybrid; USD 65,000 - 90,000; Full time

Job summary

RegalCare is seeking an Appeals Specialist (LPN, RN, or Therapist) in Massachusetts to lead clinical appeals, audits, and medical records oversight across our facility network. You will review denials, assemble compelling clinical arguments, and interface with payers to protect reimbursement while ensuring documentation compliance.

The role requires active MA licensure (RN/LPN or therapy), 2–3 years of relevant experience, and strong knowledge of Medicare/Medicaid guidelines.

Qualifications

• Active licensure as RN, LPN, or therapist (PT/OT/ST) in Massachusetts.
• 2–3 years of clinical experience in skilled nursing, long‑term care, or health‑care administration.
• Solid knowledge of Medicare Part A/B, Medicaid, and managed care guidelines; strong documentation and reimbursement rules.

Responsibilities

• Appeals Management: analyze denials, gather clinical evidence, and draft appeals to overturn determinations.
• Audit Oversight: coordinate internal/external audits with timely responses and compliant data.
• Medical Records Integrity: collaborate with Nursing leadership and therapy teams to audit records for completeness and coding accuracy.
• Clinical Collaboration: educate staff on documentation best practices to prevent future denials.
• Tracking & Reporting: maintain a centralized appeals/audit tracking system and report outcomes to leadership.

Skills

Written & verbal communication

Analytical capability

EHR proficiency

Education

RN license

LPN license

PT license

OT license

ST license

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.