[Hiring] Clinical Appeals Review Nurse @Managed Resources

Role Description

Managed Resources is seeking a detail-oriented and experienced Clinical Appeals Review Nurse to join our Clinical Appeals team. In this role, you will:

• Review denied medical claims
• Evaluate clinical documentation
• Develop well-supported appeal letters to pursue reconsideration of denied services
• Ensure appeals are accurate, thorough, and submitted in a timely manner

Your expertise plays a vital role in identifying opportunities to overturn denials, supporting appropriate reimbursement for medically necessary services, and ensuring clinical decisions are supported by established medical standards.

Qualifications

• Registered Nurse (BSN preferred)
• Certification in Case Management, Legal Nurse Consulting, or Coding a plus
• Five years of acute hospital experience is mandatory
• 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

Requirements

• Conduct secondary quality reviews of clinical appeal letters to ensure accuracy, clinical soundness, and compliance with coding, payer, and regulatory requirements prior to submission
• Review denied claims for potential provider appeals
• Evaluate medical records and supporting clinical documentation
• Assess medical necessity using established clinical criteria
• Apply clinical judgment to determine appeal eligibility
• Develop clear, accurate, and clinically supported appeal letters
• Reference medical literature, healthcare regulations, and clinical guidelines as appropriate
• Evaluate diagnoses, treatments, and services against accepted medical standards
• Assess clinical factors, including severity of illness, treatment frequency, and duration of care
• Ensure appeals are objective, professional, and evidence-based
• Submit completed appeal letters for management review and approval
• Maintain accurate appeal logs and documentation
• Complete assigned reviews accurately and within established timelines
• Prepare required payer reports and support appeal follow-up activities

Benefits

• Medical, Dental, and Vision Insurance
• Phone and Internet Stipend
• Company-Paid Life Insurance
• 401(k) Retirement Plan with Company Match
• Paid Time Off
• Seven Company-Observed Holidays
• Two Floating Holidays for Personal Observance
• Professional Development Opportunities
• Employee Recognition Programs
• Remote Work Environment