Clinical Appeals Nurse
Review denied claims, prepare clinical appeal letters, and collaborate with payers to overturn denials.
Company Overview
Helix Advisory is a leading healthcare consulting firm specializing in revenue cycle management and optimization. We work with healthcare organizations to enhance their financial performance by identifying underpayments, optimizing clinical documentation, and managing appeals processes.
Our team is dedicated to delivering exceptional results and driving innovation in healthcare finance.
Position Summary
The Clinical Appeals Nurse is responsible for reviewing denied claims, preparing clinical appeal letters, and collaborating with payers to overturn denials. This role requires a strong understanding of clinical guidelines, payer policies, and healthcare regulations.
The ideal candidate will have excellent analytical and communication skills, a keen eye for detail, and a passion for advocating on behalf of patients and providers.
Key Responsibilities
Denial Review and Analysis
- Review medical records and denial reasons to determine the validity of the denial
- Analyze clinical documentation to ensure it supports the services billed and meets payer requirements
Appeal Preparation and Submission
- Prepare detailed and persuasive appeal letters to address clinical denials
- Submit appeals to payers, ensuring compliance with payer guidelines and timelines
Collaboration and Communication
- Work closely with healthcare providers, billing staff, and coding specialists to gather necessary documentation and insights
- Communicate effectively with payers to clarify clinical information and advocate for claim approval
Education and Training
- Provide education and feedback to clinical staff on documentation improvement and denial prevention
- Stay updated on industry trends, payer policy changes, and regulatory updates to ensure best practices in appeals management
Data Tracking and Reporting
- Maintain accurate records of appeal activities, outcomes, and payer responses
- Generate reports on denial trends, appeal success rates, and areas for improvement
Qualifications
Education
- Registered Nurse (RN) with an active nursing license
- Bachelor's degree in Nursing or related field preferred
Experience
- Minimum of 2 years of experience in clinical appeals, utilization review, case management, or a related field
- Experience in a healthcare revenue cycle or billing department is a plus
Skills
- Strong clinical knowledge and the ability to interpret medical records and coding documentation
- Excellent written and verbal communication skills, with the ability to articulate clinical concepts clearly
- Detail-oriented with strong organizational and time management abilities
- Proficiency in Microsoft Office Suite (Word, Excel, Outlook) and electronic health record systems
Certifications
- Certified Clinical Documentation Specialist (CCDS) or similar certification is a plus
Why Join Helix Advisory?
- Impactful Work: Play a crucial role in ensuring patients receive the care they need and healthcare providers are fairly reimbursed
- Professional Development: Opportunities for growth and advancement in a dynamic and supportive environment
- Collaborative Team: Work with a talented team of professionals committed to excellence and innovation
- Competitive Compensation: Attractive salary and benefits package, including health insurance and retirement plans