Nurse Specialist II, Clinical Denials

Knowtion Health; United States; Remote; USD 80,000 - 110,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

Short/Long-term disability

Bonus opportunities

401k

Generous PTO

Job summary

Knowtion Health seeks an Appeals Nurse to review medical records and support denials appeals for Medicare, Medicaid, and other payers. You will craft detailed analyses and letters, aligning criteria with payer policies to secure appropriate payments.

The role requires an active RN license and 2+ years in acute care, with 3–5 years in utilization review or related areas. Remote work is supported with a strong benefits package.

Qualifications

• Licensed RN.
• 2 years’ experience in an acute care hospital.
• 3–5 years in utilization review, case management, quality assurance, discharge planning or other cost management programs preferred.
• Experience using InterQual and Milliman healthcare criteria preferred.
• Experience reviewing CMS LCD/NCD criteria preferred.
• Proficient typing and computer skills essential.

Responsibilities

• Review medical record documentation to verify medical necessity issues related to length of stay, level of care, readmissions, and related factors.
• Create detailed clinical analyses and appeal letters for denials to support payment of patient claims.
• Manage inventory and follow up on accounts as appropriate.
• Review InterQual/Milliman and payer policies and include criteria in analysis/letters as appropriate.
• Provide feedback to supervisor regarding issues for training to peers and staff.
• Identify root causes and trending to share with clients and staff.

Skills

Utilization review

Case management

Quality assurance

Discharge planning

Proficient typing

Computer skills

Education

RN license

Tools

InterQual

Milliman

CMS LCD/NCD criteria

Job description

Career Opportunities with Knowtion Health

A great place to work.

Knowtion Health participates in E-Verify

Are you seeking an exciting opportunity to join a passionate, growing, and dynamic team of professionals who support patients?

The Appeals Nurse works with attorneys and claims representatives by reviewing and appealing claims when appropriate to overturn clinical denials from Medicare, Medicaid, and other third-party payers.

What’s Attractive to the Right Candidate?

• Knowtion Health is a growing firm in a growing industry. Our status as a leader in this industry means that we have the resources to invest in the business and to innovate.
• Our business is intensely competitive and is constantly evolving. We quickly identify new challenges and develop solutions, so you won’t simply be doing what was done last year. Our new employees are frequently pleased and surprised by how quickly we make decisions and adapt to market conditions.
• Knowtion Health culture is inviting and competitive, embracing challenge and celebrating accomplishment; dedicated colleagues striving to provide quality results that have lasting impact.

The Opportunity:

• Review medical record documentation to verify medical necessity issues as related to length of stay, level of care, readmissions, experimental/investigational, etc.
• Create detailed clinical analyses and appeal letters for denials from payer to support payment of patient claims
• Managing Inventory and Following up on accounts as appropriate
• Review InterQual/Milliman and/or payer medical policies related to denied procedures or services and include criteria in analysis/appeal letter as appropriate
• Provide feedback to supervisor regarding issues identified for ongoing training to peers and non-clinical staff members
• Identify root cause and trending to share with clients and staff

What you bring:

• Licensed RN.
• At least 2 years’ experience in an acute care hospital required.
• Three to five years of experience in utilization review, case management, quality assurance, discharge planning or other cost management programs preferred.
• Experience using InterQual and Milliman healthcare criteria preferred.
• Experience reviewing CMS LCD/NCD criteria preferred.
• Proficient typing and computer skills essential.

The above statements are intended to provide the general nature and level of work being performed by most people assigned to the position. They are not intended to be an exhaustive list of all responsibilities, duties and requirements.

This position is remote and requires a dedicated, distraction-free work space at home. We offer a competitive benefits package including medical, dental, vision, life insurance, short term disability, long term disability, bonus opportunities, paid holidays, 401k, and a generous PTO policy.

Knowtion Health gives priority to applicants located in the following states: AL, AR, AZ, FL, GA, ID, IN, KS, ME, MI, MO, MS, NC, NM, OK, PA, SC, TN, TX, VA, WI, WV

Photo Identification and Image Capture Notice

As part of our hiring process, candidates are required to present a valid government‑issued photo ID during screening and/or interviews.

We may also capture a photograph during the screening or interview process for identity verification, security, and record‑keeping purposes. All identification documents and images will be handled in accordance with applicable privacy laws and accessed only by authorized personnel.

By proceeding with your application, you acknowledge and consent to this process.