Health Business Solutions LLC

Details

Join our dedicated team at HBiz where we strive to provide outstanding care and service excellence. We

are currently seeking a highly skilled Clinical Appeals Nurse to play a crucial role in managing medical

denials by providing clinical expertise in the appeals process. This position is ideal for those who excel in

analytical thinking and have a strong background in clinical practice and health information management.

Key Responsibilities:

• Review and analyze clinical documentation, utilization records, and insurance denial rationales to

formulate well-constructed appeal cases.

• Engage in the appeals process for denied claims, ensuring that all appeals are submitted in a timely

manner according to regulatory and insurer-specific requirements.

• Utilize clinical experience and knowledge in accordance with established Milliman or Interqual

guidelines to substantiate medical necessity and appropriate level of care.

• Collaborate with healthcare providers, case managers, and insurance companies to gather

additional information and advocate for proper patient services and reimbursement.

• Interpret and apply ICD-10 coding in the review of medical records to support appeal submissions.

• Maintain accurate and detailed records of all appeals processes, outcomes, and communications.

• Educate clinical staff on best practices, changes in payer requirements, and implications of clinical

documentation and coding standards.

• Active Registered Nurse (RN) license in the Philippines, US licensed preferred

• Minimum of two years of bedside clinical experience in a hospital setting.

• Proficiency with Milliman or Interqual clinical guidelines.

• Strong understanding of ICD-10 coding principles.

• Stay abreast of changes in healthcare regulations, payer policies, and clinical criteria guiding

medical necessity.

Qualifications:

• At least one year of experience in clinical appeals or utilization management.

• Bachelor’s Degree in Nursing (BSN) preferred; minimum of an Associate Degree in Nursing (ADN)

required.

• Excellent written communication skills, with the ability to articulate complex clinical information in

a clear and professional manner for appeal justifications.

• Strong organizational skills and the ability to manage multiple cases simultaneously.

Desired Skills:

• Exceptional critical thinking and problem-solving skills.

• Demonstrated ability to work independently as well as part of a team.

• Commitment to ethical medical practices and compliance with all federal and state regulations.