Clinical Appeals Analyst

Responsibilities:

• Conduct comprehensive analytic reviews of clinical documentation and patient medical records to determine insurance denial reasons.
• Write sound, compelling appeal letters using clinical evidence, regulatory guidelines, and pre-existing criteria to overturn denials professionally.
• Prepare for and participate in Administrative Law Judge hearings by providing testimony and developing well-supported appeal arguments.

Qualifications:

• Must possess a current state-issued RN license, with five years' experience as a clinical nurse in an acute care setting.
• Significant healthcare field experience is required, including case management, discharge planning, and/or utilization review.
• Knowledge of payer requirements, reimbursement regulations, InterQual Level of Care, and Milliman & Robertson criteria is essential.

Benefits and Culture:

• Joining the organization offers a collaborative work environment with exposure to various patient care levels and opportunities for professional growth.
• Competitive pay and excellent insurance options are provided, along with a generous paid benefit time program and an Education Advancement Program.
• The company is committed to high-quality patient care, outstanding customer service, and being a trusted source in the communities it serves.