Job Description

Clinical Review & Appeals RN/LPN

We are seeking an experienced Clinical Review & Appeals Nurse to join our growing team. In this role, you will evaluate and respond to QIO Appeals Requests, Health Plan Appeals Requests, and denied claim reconsiderations to ensure accurate reimbursement, medical necessity, and regulatory compliance. This position is ideal for a detail-oriented clinician with strong utilization review and appeals experience who thrives in a fast-paced, collaborative environment.

Key Responsibilities

• Review denied claims (non-administrative) to determine medical necessity using evidence-based guidelines and payer policies.
• Document clinical rationale in Tempo and escalate cases to physician reviewers when needed.
• Manage the full QIO Appeals process, including records requests, NOMNC validation, agency outreach, DENC creation, portal uploads, and follow-up for determinations.
• Process health plan and QIO appeals within regulatory and payer-specific timelines.
• Collaborate with physicians, case managers, and claims specialists to support appeals and retro-review activities.
• Maintain accurate records of all appeal activities, outcomes, and correspondence.
• Educate providers on NOMNC validity and best practices.
• Identify denial trends and provide feedback to improve processes and reduce future occurrences.

Qualifications

• Graduate of an accredited School of Nursing or Therapy.
• Active, unrestricted license as an LPN, RN, OT, PT, or SLP.
• 3–5 years of clinical experience, including 1–3 years in managed care, utilization review, or appeals/denials.
• Ability to work independently while collaborating effectively in a team environment.
• Must be able to work one of the following shifts: Tuesday–Saturday or Sunday–Thursday.

Skills & Competencies

• Strong analytical, critical thinking, and problem-solving abilities.
• Excellent written and verbal communication skills.
• Proficiency in medical terminology, clinical documentation, and coding systems.
• Familiarity with EHR systems and appeal tracking tools.

Preferred Experience

• Experience with Medicare and/or Milliman Care Guidelines (MCG).
• Knowledge of payer-specific policies and regulatory requirements.
• Background in case management or clinical documentation improvement.

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