Clinical Appeals Review Nurse

Disclaimer: This is a 1099 independent contractor position requiring a minimum commitment of 40 hours per week. The contract term is one year, with the option to renew.

Applicants will be required to submit a sample appeal letter to demonstrate relevant experience for client review.

Purpose:
Our Clinical Appeals Review services consists of reviewing and appealing for reconsideration of medical services 
that may have been denied, either in part, or in whole, during the initial claims determination phase. Denial of 
payment may be based on insufficient medical record documentation to support the level of care, billing/coding 
disputes, utilization review, determination that a treatment is investigational/experimental, and/or that the treatment 
rendered is not Medically Necessary.

Essential Job Functions:
Complete the following functions in accordance with client policies:
• The Clinical Appeals Review Nurse will review the case, and determine the potential for a Provider Appeal, 
on the denied claim.
• The request for reconsideration will be written in an objective narrative form, utilizing appropriate formatting, 
English grammar, current nationally accepted criteria, medical literature if applicable, healthcare statutes 
and clinical judgment.
• Once completed, the letter will be forwarded to the Clinical Appeals Manager for review and approval and 
then to the payer source for reconsideration.
• The Clinical Appeals Review nurse will provide the application of current prudent clinical judgment for the 
purpose of the case in question.
• The diagnosis, treatment of an illness, injury, and/or disease of its symptoms, will be in accordance with 
generally accepted standards of medical practice.
• The clinical review of the denied stay will be evaluated in terms of type, frequency, extent, site and duration 
of patient’s illness and/or injury or disease.
• The clinical review of the case will not be based on convenience factors for the patient, facility, physician, 
and/or other health care professionals.
• The Clinical Appeal Review Nurse will receive appropriate documentation which includes previous 
determination information and complete medical record for review.
• The review will be written in a narrative, professional manner, with an appropriate review of the clinical 
facts. The letter will include the medically appropriate reasons for the reconsideration of the denial.
• Once the review is completed, the Clinical Appeal Review Nurse will forward the reconsideration letter to 
corporate office, through secure website, for review by the Clinical Appeals Manager. Once approved, the 
letter is mailed with attached medical records to the appropriate entity.
• The Clinical Appeals Review Nurse will then update the applicable logs for appropriate follow up purposes 
including payor requested reports.

Ideal candidate will possess the following:

REQUIRED

• Must be able to commit to a MINIMUM of 40 hours per week

• Must have experience in Utilization Review

• Must have experience in writing quality appeal letters to achieve maximum overturn rate (this client requires sample appeal letters for consideration)

• RN with comparable experience and background. Certification in Case Management, Legal 
Nurse Consulting, or Coding a plus. 
• Five years of acute hospital experience mandatory.
• Possess knowledge and experience with national clinical criteria applied in case management including 
InterQual and Milliman standards. 
• Working knowledge of billing codes, Revenue Codes, CPT’s, etc. Experience with case management software 
such as Midas preferred.
• Experience and knowledge of managed care contracts, account receivables and revenue cycle functions. 
• Working knowledge of provider billing guidelines, payer reimbursement policies, and related industry based 
standards. 
• Experience and success in appealing managed care denials and underpayment decisions. 
• Ability to examine financial and clinical data trends and provide recommended action steps to resolve. 

PREFERRED

• BSN, MSN

• CDIP and/or CCS

Tools & equipment:
Computer, mobile phone

Working Environment:
Normal remote home business office conditions