Clinical Appeals Specialist

Role overview

The Clinical Appeals Specialist handles clinical denial cases by thoroughly reviewing medical records and related documentation, then drafting timely, well-supported appeal responses grounded in medical necessity standards, physician notes, clinical evidence, and the payer’s policies. The role also tracks denial patterns, shares findings with patient accounting leadership, and helps refine the organization’s clinical denial and appeal workflow to reduce revenue loss.

Working arrangement

This is a full-time remote role, scheduled primarily Monday through Friday from 8:00 AM to 5:00 PM. The FTE is 1.0. Because the position is remote, candidates must have dependable broadband internet and a personal mobile phone service. Day-to-day work and any online training may follow Pacific Standard Time business hours. Applicants must live in the United States, and some states are excluded based on pay policies.

Responsibilities

• Review clinical denial cases and assess the supporting documentation in detail.
• Prepare clear, timely, and defensible written appeals based on medical necessity and payer requirements.
• Use physician documentation, evidence-based criteria, and medical policies to support appeal decisions.
• Identify denial trends and communicate them to patient accounting leadership.
• Work with patient accounting teams to strengthen the organization’s denial and appeal process.
• Support education and performance improvement efforts aimed at improving clinical quality, efficiency, and reimbursement outcomes.
• Help reduce revenue loss associated with medical necessity denials.

Requirements

• At least 3 years of clinical RN experience is required.
• At least 1 year of denial management, case management, or a similar role is required.
• At least 1 year of current experience with reimbursement methodologies is required.
• Experience writing appeals for clinical denials is preferred.
• A bachelor’s degree in nursing or an allied health field, or an equivalent qualification, is preferred.
• Registered Nurse licensure from the Oregon State Board of Nursing is required.
• CCDS certification from ACDIS is preferred.
• Certified Case Manager (CCM) certification is preferred.
• Reliable broadband internet and personal cell phone service are required for remote work.
• Candidate must reside in the United States, with some states not eligible under company pay practices.

Benefits

• Competitive market-based pay for hourly and salaried roles.
• Medical, dental, and vision insurance for part-time and eligible employees, with coverage beginning within 30 days of hire.
• Employer-sponsored retirement plan with company contribution and matching.
• Generous earned time off for part-time and eligible employees.
• Tuition reimbursement and tuition repayment support for continued education.
• Life insurance, disability coverage, and employee assistance programs.

Values and employer commitment

The organization is guided by the values of excellence, respect, honesty, service, and teamwork. It also maintains an equal opportunity hiring approach and supports a diverse and inclusive workplace for women, minorities, individuals with disabilities, and protected veterans.