Clinical Appeals NurseHealth Business Solutions LLC • Florida, New York, United States
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Clinical Appeals Nurse
Health Business Solutions LLC
- Florida, New York, United States
- Florida, New York, United States
Über
Status:
Exempt
Location:
Remote
Department:
Clinical Appeals
Reports To:
Director of Clinical Appeals
Position Overview The Clinical Appeals Nurse supports HBiz’s revenue cycle operations by reviewing denied claims for clinical accuracy and medical necessity, developing evidence-based appeal strategies, and drafting payer-ready appeal documentation. This role plays a critical part in overturning denials, improving reimbursement outcomes, and ensuring compliance with payer policies and clinical standards.
Key Responsibilities
Review medical records and payer denial rationale to determine appeal opportunities
Assess medical necessity using clinical guidelines, payer policies, and regulatory standards
Draft clear, concise, and evidence-based appeal letters for multiple levels of appeal
Collaborate with coding, CDI, denial recovery, and operations teams to strengthen appeal strategy
Identify documentation gaps and recommend improvements to reduce future denials
Support peer-to-peer review preparation and provide clinical insight when needed
Track appeal outcomes and contribute to reporting on overturn rates and trends
Maintain compliance with HIPAA, payer requirements, and client confidentiality standards
Participate in process improvement initiatives to enhance appeal success and efficiency
Qualifications Required
Active Registered Nurse (RN) license in the United States
Minimum 3–5 years of clinical nursing experience
Strong understanding of medical necessity criteria and payer review processes
Experience reviewing medical records and clinical documentation
Excellent written communication skills with the ability to translate clinical information into persuasive appeal narratives
Preferred
Prior experience in utilization review, case management, CDI, or clinical appeals
Familiarity with CMS guidelines, InterQual, Milliman, or similar criteria
Experience in hospital or payer-facing environments
Bachelor of Science in Nursing (BSN)
Core Competencies
Clinical judgment and analytical thinking
Strong written and verbal communication
Detail-oriented documentation review
Ability to manage multiple appeals and deadlines
Collaboration across clinical and operational teams
Success Measures
Appeal overturn rate and recovery contribution
Quality and clarity of appeal documentation
Timeliness of appeal submission
Identification of systemic denial trends and improvement opportunities
HBiz Work Environment HBiz partners with healthcare organizations nationwide to improve revenue performance and operational efficiency. This role requires strong clinical reasoning, adaptability, and collaboration across departments to ensure our clients receive appropriate reimbursement for medically necessary services.
HBiz Approval & Disclaimer This job description is intended to describe the general nature and level of work performed by individuals assigned to this position. It is not intended to be an exhaustive list of all duties, responsibilities, or qualifications required. Responsibilities may change based on business needs, client requirements, or operational priorities.
HBiz reserves the right to modify this job description at any time, with or without notice.
Employment with HBiz is at-will, meaning either the employee or the company may terminate employment at any time, with or without cause or notice, subject to applicable law.
HBiz is an Equal Opportunity Employer and is committed to providing a workplace free from discrimination and harassment. We celebrate diversity and are committed to creating an inclusive environment for all employees.
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Sprachkenntnisse
- English
Hinweis für Nutzer
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