Clinical Appeals Nurse

Health Business Solutions LLC; United States; Remote; USD 70,000 - 100,000; Full time

Job summary

Health Business Solutions LLC is seeking a Clinical Appeals Nurse (RN) for a remote role. The position focuses on reviewing denied claims for clinical accuracy and medical necessity, developing appeal strategies, and drafting payer-ready documentation to overturn denials and improve reimbursement outcomes.

The role requires an active US RN license and 3–5 years of clinical nursing experience, with preferred BSN.

Qualifications

• Active Registered Nurse license in the United States.
• 3–5 years of clinical nursing experience.
• Strong understanding of medical necessity criteria and payer review processes.
• Experience reviewing medical records and clinical documentation.
• Excellent written communication skills for persuasive appeal narratives.

Responsibilities

• Review medical records and denial rationale to identify appeal opportunities.
• Assess medical necessity using guidelines, payer policies, and regulatory standards.
• Draft payer-ready appeal letters for multiple levels of appeal.
• Collaborate with coding, CDI, denial recovery, and operations teams to strengthen strategy.
• Identify documentation gaps and recommend improvements to reduce denials.
• Support peer-to-peer review preparation and provide clinical insight.
• Track appeal outcomes and contribute to reports on overturn rates and trends.
• Maintain HIPAA compliance and client confidentiality.
• Participate in process improvement initiatives to boost success and efficiency.

Skills

RN license (US)

3–5 years clinical nursing

Medical necessity criteria

Medical records review

Written communication

Education

BSN (preferred)

Job description

Clinical Appeals Nurse (RN)

Status: Exempt Location: Remote Department: Clinical Appeals Reports To: Director of Clinical Appeals

Position Overview

The Clinical Appeals Nurse supports HBiz's revenue cycle operations by reviewing denied claims for clinical accuracy and medical necessity, developing evidence-based appeal strategies, and drafting payer-ready appeal documentation. This role plays a critical part in overturning denials, improving reimbursement outcomes, and ensuring compliance with payer policies and clinical standards.

Key Responsibilities

• Review medical records and payer denial rationale to determine appeal opportunities
• Assess medical necessity using clinical guidelines, payer policies, and regulatory standards
• Draft clear, concise, and evidence-based appeal letters for multiple levels of appeal
• Collaborate with coding, CDI, denial recovery, and operations teams to strengthen appeal strategy
• Identify documentation gaps and recommend improvements to reduce future denials
• Support peer-to-peer review preparation and provide clinical insight when needed
• Track appeal outcomes and contribute to reporting on overturn rates and trends
• Maintain compliance with HIPAA, payer requirements, and client confidentiality standards
• Participate in process improvement initiatives to enhance appeal success and efficiency

Qualifications

Required

• Active Registered Nurse (RN) license in the United States
• Minimum 3-5 years of clinical nursing experience
• Strong understanding of medical necessity criteria and payer review processes
• Experience reviewing medical records and clinical documentation
• Excellent written communication skills with the ability to translate clinical information into persuasive appeal narratives

Preferred

• Prior experience in utilization review, case management, CDI, or clinical appeals
• Familiarity with CMS guidelines, InterQual, Milliman, or similar criteria
• Experience in hospital or payer-facing environments
• Bachelor of Science in Nursing (BSN)

Core Competencies

• Clinical judgment and analytical thinking
• Strong written and verbal communication
• Detail-oriented documentation review
• Ability to manage multiple appeals and deadlines
• Collaboration across clinical and operational teams

Success Measures

• Appeal overturn rate and recovery contribution
• Quality and clarity of appeal documentation
• Timeliness of appeal submission
• Identification of systemic denial trends and improvement opportunities

HBiz Work Environment

HBiz partners with healthcare organizations nationwide to improve revenue performance and operational efficiency. This role requires strong clinical reasoning, adaptability, and collaboration across departments to ensure our clients receive appropriate reimbursement for medically necessary services.

HBiz Approval & Disclaimer

This job description is intended to describe the general nature and level of work performed by individuals assigned to this position. It is not intended to be an exhaustive list of all duties, responsibilities, or qualifications required. Responsibilities may change based on business needs, client requirements, or operational priorities.

HBiz reserves the right to modify this job description at any time, with or without notice.

Employment with HBiz is at-will, meaning either the employee or the company may terminate employment at any time, with or without cause or notice, subject to applicable law.

HBiz is an Equal Opportunity Employer and is committed to providing a workplace free from discrimination and harassment. We celebrate diversity and are committed to creating an inclusive environment for all employees.