Appeals Nurse Coordinator

This is a fully remote position, open to applicants in Tennessee.

📋 Description

• Conduct clinical evaluations in line with managed care, payer, and CMS standards.

• Assist in assessing the appropriate level of care and medical necessity.

• Analyze clinical documentation pertinent to ICD-10 coding and DRG assignment.

• Aid in denial management and the preparation of appeal communications.

• Assess whether documentation validates the care delivered and meets relevant coding or reimbursement criteria.

• Offer insights to internal and external stakeholders regarding care levels, length of stay, case outcomes, and clinical documentation.

• Identify areas for clarification or the need for additional medical record documentation.

• Utilize pertinent clinical and industry guidelines during case reviews.

• Review cases employing applicable utilization management and clinical documentation resources.

• Leverage AI-enabled tools to enhance research, documentation review, workflow efficiency, and case analysis.

• Investigate payer policies, contracts, and regulatory frameworks.

• Interact with payers and clients concerning claim determinations and appeal justifications.

• Keep abreast of ongoing regulatory changes, clinical practices, payer demands, healthcare technologies, and industry benchmarks.

• Record findings and identify trends or information pertinent to client requirements.

• Execute other related responsibilities as assigned.

• Operate independently without supervisory duties.

• Travel to home offices in Tennessee for training purposes.

⛳️ Requirements

• Valid RN or LPN license.

• Clinical nursing background.

• Experience in reviewing and interpreting medical records.

• Knowledge of healthcare reimbursement, medical necessity, utilization management, denial and appeals processes, clinical documentation, or similar functions.

• Understanding of ICD-10, DRG concepts, and electronic medical records.

• Familiarity with AI-enabled tools or other healthcare technologies that facilitate clinical, documentation, research, or administrative workflows.

• Proficiency in standard business software, including Microsoft Word and Excel.

• Experience in utilization review, case management, auditing, denial and appeals processes, Clinical Documentation Improvement (CDI), or DRG clinical validation.

• Knowledge of InterQual, MCG, CMS medical necessity standards, and the Two-Midnight Rule.

• Familiarity with CDI resources and guidance, including ACDIS and similar industry materials.

• Experience with electronic medical record systems such as Epic, Cerner, or Meditech.

• Experience employing AI-enabled tools in clinical review, documentation, research, appeals, or other healthcare processes.

• Certification in case management, coding, utilization review, or CDI.

• Must already possess authorization to work in the United States on a full-time, permanent basis without current or future sponsorship.

• Must successfully complete a background check.

🏝️ Benefits

• Medical/Dental/Vision insurance.

• 401K company match.

• Flexible Paid Time Off.

• Paid parental leave.

• HSA/FSA options.

• Educational reimbursement program.

• Employer-paid EAP & Mental Health services.