Clinical Appeals & Reimbursement Specialist

Regalcare; Holyoke (MA); Hybrid; USD 65,000 - 90,000; Full time

Job summary

RegalCare is seeking an Appeals Specialist (LPN, RN, or Therapist) in Massachusetts with hybrid-remote options. You will lead clinical appeals, audit management, and medical records oversight to protect reimbursement and ensure documentation compliance across our Massachusetts facilities.

Responsibilities include analyzing denials, coordinating audits, auditing medical records for completeness and coding accuracy, and educating clinical teams to prevent future denials.

Qualifications

• Active, unencumbered Massachusetts license as RN, LPN, or therapist (PT/OT/ST).
• 2–3 years of clinical experience in skilled nursing, long-term care, or healthcare administration.
• Knowledge of Medicare Part A/B, Medicaid, and managed care guidelines.
• Proficiency with electronic health record (EHR) systems and strong written/verbal communication.

Responsibilities

• Analyze insurance denials, Medicare/Medicaid rejections, and managed care disputes; draft comprehensive appeals.
• Coordinate internal and external clinical audits with timely responses.
• Audit medical records for completeness, clinical necessity, and coding accuracy.
• Educate staff on proper documentation habits to prevent future denials.
• Maintain a centralized tracking system for all pending appeals and audit outcomes.

Skills

Written communication

Verbal communication

Analytical

Detail oriented

Tools

EHR systems

Job description

RegalCare is seeking an Appeals Specialist (LPN, RN, or Therapist) in Massachusetts with hybrid-remote options. You will lead clinical appeals, audit management, and medical records oversight to protect reimbursement and ensure documentation compliance across our Massachusetts facilities.

Responsibilities include analyzing denials, coordinating audits, auditing medical records for completeness and coding accuracy, and educating clinical teams to prevent future denials.