RN, Appeals and Grievance Registered Nurse II – Clinical Appeals – PRN

Job Description

Summary:
The Clinical Appeals Nurse is responsible for managing and communicating denials and appeals from third-party payers regarding medical necessity and level of care. This role involves reviewing cases based on established guidelines, determining appeal viability, and managing the appeal process. The nurse will also track denial trends, educate stakeholders, and implement performance improvement initiatives to enhance clinical quality and reduce revenue loss.

Responsibilities:

• Analyze governmental denial rationales and provide appeal services.
• Review medical records against contractor response letters.
• Communicate with facilities about documentation issues.
• Draft appeal letters based on Medicare guidelines.
• Research relevant laws and regulations.
• Coordinate with healthcare team to identify denial causes.
• Ensure timely filing of appeals and maintain denial databases.

Requirements:
Associate’s Degree in Nursing and RN License in the state of employment.

Work Type:
Per Diem As Needed