RN Appeals Specialist: Medical Necessity & Denials

Xsolis, Inc; Oregon; Hybrid; USD 80,000 - 110,000; Full time

Benefits offered by this job

Medical/Dental/Vision insurance

401K company match

Flexible Paid Time Off

Paid parental leave

HSA/FSA options

Educational reimbursement program

EAP & Mental Health services

Job summary

XSOLIS is seeking an Appeals Nurse Coordinator II to provide concurrent review and appeals support for clients. The role evaluates medical necessity, level of care, and documentation for ICD-10/DRG, leveraging AI-enabled tools to enhance clinical reviews.

The ideal candidate is an RN with utilization management and appeals experience, proficient in EMRs, and with strong communication and organizational skills. Some travel to training in TN is required.

Qualifications

• Active RN or LPN license.
• Clinical nursing experience.
• Experience reviewing and interpreting medical records.
• Strong written and verbal communication.
• Ability to organize, prioritize, and manage multiple cases.
• Familiarity with healthcare reimbursement, medical necessity, utilization management, denials and appeals, clinical documentation, or related functions.
• Familiarity with ICD-10, DRG concepts, and electronic medical records.
• Familiarity with AI-enabled tools or other healthcare technology used to support clinical, documentation, research, or administrative workflows.
• Proficiency with common business applications, including Microsoft Word and Excel.

Responsibilities

• Perform clinical reviews in accordance with managed care, payer, and CMS requirements.
• Assist with determining appropriate level of care and medical necessity.
• Review clinical documentation related to ICD-10 coding and DRG assignment.
• Support denial management and preparation of appeal correspondence.
• Evaluate whether documentation supports the care provided and applicable coding or reimbursement requirements.
• Provide feedback to internal and external partners regarding level of care, length of stay, case outcomes, and clinical documentation.
• Identify opportunities for clarification or additional medical-record documentation.
• Apply relevant clinical and industry guidelines when reviewing cases.
• Review cases using applicable utilization management and clinical documentation resources.
• Use available technology, including AI-enabled tools, to support research, documentation review, workflow efficiency, and case analysis as appropriate.
• Research payer policies, contracts, and regulatory requirements as needed.
• Communicate with payers and clients regarding claim determinations and appeal rationale.
• Maintain current knowledge of regulatory changes, clinical practice, payer requirements, healthcare technology, and industry standards.
• Document findings and identify trends or other information relevant to client needs.
• Perform other related duties as assigned.

Skills

RN license

Clinical nursing experience

Medical record review

Communication skills

Case management familiarity

ICD-10/DRG knowledge

AI-enabled tools experience

Tools

Microsoft Word

Excel

Job description

XSOLIS is seeking an Appeals Nurse Coordinator II to provide concurrent review and appeals support for clients. The role evaluates medical necessity, level of care, and documentation for ICD-10/DRG, leveraging AI-enabled tools to enhance clinical reviews.

The ideal candidate is an RN with utilization management and appeals experience, proficient in EMRs, and with strong communication and organizational skills. Some travel to training in TN is required.