Clinical Appeals Nurse - PRN

About the role

Responsible for reviewing medical records and preparing clinical appeals in response to medical necessity denials and diagnosis-related groups (DRG) reassignments.

Responsibilities

• Prepare and submit clinical appeals in response to denials from managed care organizations, governmental entities, and Recovery Audit Contractors (RACs) for hospital clients.
• Review medical records and utilize industry guidelines, Medicare policies, and best practice standards to support appeal arguments.
• Participate in Administrative Law Judge (ALJ) Hearings, presenting oral arguments to support the reversal of Medicare denials.
• Analyze denial patterns and contribute insights to help reduce future denials.
• Collaborate with the appeals team and hospital clients to provide updates on appeal statuses and outcomes.
• Maintain current knowledge of healthcare regulations, coding guidelines, and payer policies relevant to the appeals process.

Requirements

• Bachelor's of Science in Nursing (BSN) or equivalent degree.
• Current and unrestricted RN license.
• At least 5 years of clinical experience in acute care settings.
• At least 3 years of experience in case management, utilization review, or clinical appeals.
• Exceptional written and verbal communication skills.
• Proficiency with MS Office suite, particularly Word and Excel.
• Strong analytical and problem-solving skills with attention to detail.

Preferred Qualifications

• Experience with payer-side case management or medical director-level review.

Expectations

• Comfortable with remote work arrangements and virtual collaboration tools.
• May require occasional travel for conferences, client meetings, or in-person hearings.

Physical Demands

• Extended periods of sitting, computer use, and telephone communication.

All applicants must be legally authorized to work in the United States. Netsmart does not provide work visa sponsorship for this position.