Clinical Appeals Nurse

Join our dedicated team at HBiz where we strive to provide outstanding care and service excellence. We are currently seeking a highly skilled Clinical Appeals Nurse to play a crucial role in managing medical denials by providing clinical expertise in the appeals process. This position is ideal for those who excel in analytical thinking and have a strong background in clinical practice and health information management.

Key Responsibilities:

1. Review and analyze clinical documentation, utilization records, and insurance denial rationales to formulate well-constructed appeal cases.
2. Engage in the appeals process for denied claims, ensuring that all appeals are submitted in a timely manner according to regulatory and insurer-specific requirements.
3. Utilize clinical experience and knowledge in accordance with established Milliman or Interqual guidelines to substantiate medical necessity and appropriate level of care.
4. Collaborate with healthcare providers, case managers, and insurance companies to gather additional information and advocate for proper patient services and reimbursement.
5. Interpret and apply ICD-10 coding in the review of medical records to support appeal submissions.
6. Maintain accurate and detailed records of all appeals processes, outcomes, and communications.
7. Educate clinical staff on best practices, changes in payer requirements, and implications of clinical documentation and coding standards.
8. Stay abreast of changes in healthcare regulations, payer policies, and clinical criteria guiding medical necessity.

Required Qualifications:

• Active Registered Nurse (RN) license in the Philippines, US licensed preferred
• Minimum of two years of bedside clinical experience in a hospital setting.
• At least one year of experience in clinical appeals or utilization management.
• Bachelor’s Degree in Nursing (BSN) preferred; minimum of an Associate Degree in Nursing (ADN) required.
• Proficiency with Milliman or Interqual clinical guidelines.
• Strong understanding of ICD-10 coding principles.
• Excellent written communication skills, with the ability to articulate complex clinical information in a clear and professional manner for appeal justifications.
• Strong organizational skills and the ability to manage multiple cases simultaneously.

Desired Skills:

• Exceptional critical thinking and problem-solving skills.
• Demonstrated ability to work independently as well as part of a team.
• Commitment to ethical medical practices and compliance with all federal and state regulations.

What We Offer:

• Competitive salary and benefits package including health and paid time off.
• Opportunities for professional growth and continuing education.
• Supportive work environment focused on teamwork and positive outcomes.
• HBiz is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
• We look forward to considering your application and hopefully welcoming you to our team!