Clinical Appeals Specialist II - Hybrid

Role Overview This hybrid RN position requires candidates to be located within 100 miles of a healthcare campus. The primary responsibilities include reviewing clinically related claim denials, conducting payer audits, and preparing appeal responses. The role involves evaluating medical records against criteria and contract requirements using clinical expertise and critical thinking. Additionally, the role serves as a liaison to revenue cycle, case management, and practice stakeholders, providing feedback to prevent denials. Qualifications & Skills Associates Degree with a minimum of 3 years of relevant nursing experienceActive unrestricted RN licensePreferred experience in prior authorization, utilization review, denials, appeals, coding (ICD-10-CM/PCS), DRG reimbursement, and clinical validation principlesKnowledge of Medicare/Medicaid claims, payer policies, and regulatory standardsFamiliarity with Epic, Microsoft Office, and data entry skillsExcellent communication, organization, problem-solving, and analytical skillsCertifications such as HFMA, CCDS, or CDIP are preferred Key Duties Review and appeal clinically related denials and payer correspondenceUtilize clinical judgment to evaluate medical records against criteriaCollaborate with stakeholders to prevent denials and improve processes Note: This position is not eligible for sponsorship. The salary range is $88,358 - $123,780 annually, with full-time benefits.