Senior Clinical Appeals & Patient Advocacy Nurse (Remote)

Managed Resources is seeking a highly skilled and compassionate Senior Clinical Appeals & Patient Advocacy Nurse (RN) to join our dynamic team! This is a fantastic opportunity for a seasoned nursing professional with a passion for advocating for patients and ensuring fair healthcare reimbursement. As a key member of our team, you will play a critical role in reviewing and appealing denied medical claims, leveraging your clinical expertise to achieve positive patient outcomes and maximize revenue for our healthcare clients nationwide.

About Managed Resources: Managed Resources is a leading consulting group dedicated to optimizing revenue cycle management for healthcare organizations. We achieve this through comprehensive review, strategic recovery efforts, and impactful educational programs. We pride ourselves on providing innovative, consultative solutions and fostering strong partnerships with our clients. We are committed to being the most trusted and innovative revenue cycle partner in the nation.

Job Highlights:

• Position: Senior Clinical Appeals & Patient Advocacy Nurse (RN)
• Compensation: Competitive salary commensurate with experience (ranging from $30.00 - $40.00 per hour)
• Start Date: Immediate openings available
• Location: Fully Remote – Work from the comfort of your own home!
• Company: Managed Resources
• Employment Type: Full-time

Purpose of the Role

As a Senior Clinical Appeals & Patient Advocacy Nurse, you will be responsible for meticulously reviewing denied medical claims, identifying opportunities for successful appeals, and advocating for patients to ensure they receive appropriate reimbursement for the services they have rendered. Your clinical expertise and strong communication skills will be instrumental in crafting compelling and persuasive appeal letters that leverage medical documentation, clinical criteria, and relevant healthcare regulations. You will be a champion for patients, ensuring their needs are met and their rights are protected throughout the appeals process.

Reporting Structure

You will report to the Assistant Manager of Clinical Appeals, working collaboratively within a supportive and results-oriented team.

Key Responsibilities & Essential Job Functions:

• Comprehensive Claim Review: Thoroughly review denied medical claims, including patient medical records, billing documentation, and payer communications, to understand the reason for denial.
• Appeal Strategy Development: Analyze the denial reasons and develop a strategic plan for appeal, identifying key arguments and supporting evidence.
• Persuasive Appeal Letter Writing: Craft compelling and well-documented appeal letters that clearly articulate the medical necessity of services, address payer concerns, and leverage clinical criteria (e.g., InterQual, Millman). Ensure all letters adhere to established formatting guidelines, grammar, and professional communication standards.
• Clinical Expertise & Judgment: Apply sound clinical judgment and expertise to evaluate the appropriateness of medical services and the validity of the denial. Ensure all appeals are grounded in evidence-based medical practice.
• Compliance & Accuracy: Ensure all appeals are submitted in compliance with payer regulations, healthcare statutes, and Managed Resources' internal policies and procedures.
• Documentation & Reporting: Maintain accurate and detailed documentation of all appeals activities, including case summaries, appeal strategies, and communication with payers. Update relevant logs and reports as required.
• Collaboration & Communication: Collaborate effectively with the Clinical Appeals Manager, other team members, and clients to ensure seamless appeal processing and positive outcomes.
• Staying Current: Continuously stay informed about changes in healthcare regulations, payer policies, and clinical guidelines.
• Patient Advocacy: Act as an advocate for patients, ensuring their voices are heard and their needs are considered throughout the appeals process.
• Data Analysis: Examine financial and clinical data trends to identify areas for improvement in the appeals process and recommend action steps to resolve recurring denial issues.

Qualifications & Requirements:

• RN License: Valid and active Registered Nurse (RN) license required.
• Experience: Minimum of five (5) years of acute hospital experience is mandatory.
• Certification (Preferred): Certification in Case Management, Legal Nurse Consulting, or Coding is a plus.
• Clinical Criteria Expertise: Demonstrated knowledge and experience with national clinical criteria applied in case management, including InterQual and Milliman standards.
• Billing & Coding Knowledge: Working knowledge of billing codes (e.g., ICD-10, CPT), Revenue Codes, and other relevant coding systems. Experience with case management software such as Midas is highly preferred.
• Managed Care Experience: Experience and knowledge of managed care contracts, accounts receivable, and revenue cycle functions.
• Payer Policy Knowledge: Working knowledge of provider billing guidelines, payer reimbursement policies, and related industry-based standards.
• Appeals Success: Proven experience and success in appealing managed care denials and underpayment decisions.
• Analytical Skills: Strong analytical and problem-solving skills, with the ability to examine financial and clinical data trends and provide recommended action steps.
• Communication Skills: Excellent written and verbal communication skills, with the ability to clearly and persuasively articulate complex medical information.
• Computer Proficiency: Proficient in Microsoft Office Suite (Word, Excel, Outlook) and comfortable using secure online platforms.

Benefits & Perks:

Managed Resources offers a comprehensive benefits package, including:

• 401(k) with company matching
• Dental insurance
• Disability insurance
• Employee Assistance Program
• Flexible Spending Account
• Health insurance
• Life insurance
• Paid time off
• Referral program
• Vision insurance
• Pet Insurance
• Monthly Internet Stipend

Our Vision:

To become the most trusted, innovative, and consultative revenue cycle partner in the nation.

Ready to make a difference? Visit http://jobs.managedresourcesi.com to explore more career opportunities and sign up for job alerts.

Managed Resources is an Equal Opportunity Employer (EOE) – M/F/D/V/SO. Apply Now! Apply To This Job