Clinical Appeals Nurse

Netsmart; United States; Remote; USD 70,000 - 90,000; Full time

Job summary

A healthcare technology company is seeking a Clinical Appeals Nurse to join their team. You will review clinical documentation and craft appeal letters to overturn denied claims, making a significant impact on patient care. Candidates should have at least a BSN, an RN license, and substantial clinical experience. The position allows for remote work and collaboration with a dynamic team.

Qualifications

• At least 5 years of clinical experience in acute care settings.
• At least 3 years of experience in case management, utilization review, or clinical appeals.
• Experience with payer-side case management is preferred.

Responsibilities

• Prepare and submit clinical appeals in response to denials.
• Review medical records to support appeal arguments.
• Participate in ALJ Hearings to present oral arguments.
• Analyze denial patterns to reduce future denials.
• Collaborate with the appeals team to update on appeal statuses.

Skills

Detail-oriented

Self-motivated

Advocacy through clinical writing

Exceptional written communication skills

Strong analytical skills

Problem-solving skills

Education

Bachelor's of Science in Nursing (BSN)

Current and unrestricted RN license

Tools

MS Office suite (Word, Excel)

Job description

Overview

Join a high-performing team of nurses who specialize in writing clinical appeals to help overturn denied claims. Our team of nurses make a meaningful impact on patient care and reimbursement outcomes. As a Clinical Appeals Nurse, you’ll be assigned cases through our software platform and work independently to review clinical documentation and craft compelling appeal letters. This role is ideal for nurses who are detail-oriented, self-motivated, and passionate about advocacy through clinical writing.

Key Responsibilities

• Prepare and submit clinical appeals in response to denials from managed care organizations, governmental entities, and Recovery Audit Contractors (RACs) for hospital clients
• Review medical records and utilize industry guidelines, Medicare policies, and best practice standards to support appeal arguments
• Participate in Administrative Law Judge (ALJ) Hearings, presenting oral arguments to support the reversal of Medicare denials
• Analyze denial patterns and contribute insights to help reduce future denials
• Collaborate with the appeals team and hospital clients to provide updates on appeal statuses and outcomes
• Maintain current knowledge of healthcare regulations, coding guidelines, and payer policies relevant to the appeals process

Qualifications

Required

• Bachelor's of Science in Nursing (BSN) or equivalent degree
• Current and unrestricted RN license
• At least 5 years of clinical experience in acute care settings
• At least 3 years of experience in case management, utilization review, or clinical appeals
• Exceptional written and verbal communication skills
• Proficiency with MS Office suite, particularly Word and Excel
• Strong analytical and problem-solving skills with attention to detail

Preferred

• Experience with payer-side case management or medical director-level review

Expectations

• Comfortable with remote work arrangements and virtual collaboration tools
• May require occasional travel for conferences, client meetings, or in-person hearings
• Physical demands include extended periods of sitting, computer use, and telephone communication

Netsmart is an equal opportunity workplace and is an affirmative action employer, providing equal employment and advancement opportunities to all individuals. We celebrate diversity and are committed to creating an inclusive environment for all associates. All employment decisions at Netsmart, including but not limited to recruiting, hiring, promotion and transfer, are based on performance, qualifications, abilities, education and experience. Netsmart does not discriminate in employment opportunities or practices based on race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, national origin, age, physical or mental disability, past or present military service, or any other status protected by the laws or regulations in the locations where we operate.

Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart’s sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart’s third party screening provider.

If you are located in a state which grants you the right to receive information on salary range, pay scale, description of benefits or other compensation for this position, please request details which you may be legally entitled.

All applicants for employment must be legally authorized to work in the United States. Netsmart does not provide work visa sponsorship for this position.

Netsmart's Job Applicant Privacy Notice may be found by contacting Netsmart for more information.