Clinical Appeals Nurse

The Remote Clinical Denials RN is responsible for review, analysis and appeal of clinical denials from insurance companies and third-party payers. This role requires a strong clinical background, knowledge of medical necessity criteria, and expertise in appealing denied claims. Essential Job Functions: Medical Necessity Reviews, Ensure documentation integrity, Construct warranted appeals, Coordinate pre-service authorization approvals. Duties and Responsibilities: Conduct comprehensive Denial Root-cause analysis, Retrospective Medical Record reviews to assure complete and accurate physician/staff documentation is present to support medical necessity Collaboration with hospital Patient Access and Mid-Revenue Cycle Research and application of regulatory policies to support clinical appeal Telephonic communication with payors, provider, hospital staff and patient/family as necessary to bring the account into resolution.