Nurse Specialist – Clinical Denials and Appeals

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

📋 Description

• Accountable for assessing denied claims and executing the appeals process effectively and promptly.

• Recognizes and addresses denials by responding to the reasons provided and resubmitting any necessary information to the payor.

• Manage denials and appeals in a timely manner, analyzing the denial reasons along with payor information and policies, reviewing clinical documentation, evaluating options, and completing subsequent actions.

• Submit retro-authorizations per payor specifications in response to authorization denials.

• Conduct medical necessity evaluations based on the root causes of denials, preparing any necessary clinical documentation summaries to accompany appeals.

• Compose and submit written appeals that include persuasive arguments grounded in clinical documentation, third-party payer medical policies, and contractual language.

• Record all actions taken and conduct timely follow-ups regarding the resolution of denials and appeals with third-party payers.

• Perform relevant research to aid in the appeals process and keep updated on best practices and policy changes.

• Adhere to state and federal laws, accreditation/compliance standards, and Huron’s policies, particularly those concerning fraud and abuse, confidentiality, and HIPAA.

⛳️ Requirements

• A minimum of 1 year of experience in clinical appeal writing.

• At least 3-5 years of acute care clinical experience in a hospital environment (Med/Surg or similar preferred); 2-3 years if ICU experience.

• Associate Degree in Nursing (ADN) or a Diploma in Nursing.

• Must possess an active USRN license as a Registered Nurse.

• Proficient in utilizing InterQual or MCG clinical guidelines.

• Extensive knowledge of U.S. Government Programs and Insurance Regulations.

• Familiarity with hospital-based electronic medical records (EMR) such as Epic, Cerner, or Meditech.

• Certification in case management, clinical appeals, or clinical denials (ACMA) is preferred.

• Skilled in using Microsoft Office Suite (Excel, Word, PowerPoint, Outlook, SharePoint).

🏝️ Benefits

• Medical, dental, and vision insurance coverage.

• Employee stock purchase plan.

• 401(k) plan with a substantial employer match.

• Paid Time Off policy.

• Paid parental leave and adoption support.

• Complimentary annual health screenings and coaching.