Clinical Appeals Nurse

Appeals Management:

• Creates appeal letters based on medical policy guidelines and documentation.
• Facilitates write-offs for accounts lacking medical necessity.
• Coordinates appeals requiring physician input and writes off claims with no further appeal rights.

Documentation and Compliance:

• Investigates and coordinates completion of patient records for retrospective precertification and appeals.
• Ensures all appeals are sent to the correct payor within guidelines.
• Reviews claim documentation and pulls supporting medical evidence from systems.

Payor Relations:

• Contacts insurance companies via phone or email to conduct appeals.
• Identifies areas for revenue loss due to documentation or process issues.
• Reports payor trends to management.