Hybrid Clinical Appeals Specialist (RN/LPN/Therapist)

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

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.