RN Clinical Appeals Specialist

Job Description

Job Title : RN Clinical Appeals Specialist

Department : Revenue Cycle - Denial Management

Location : Onsite-Evanston, IL

Schedule : Monday - Friday | 7 : 00 AM - 4 : 00 PM (Latest start time : 8 : 00 AM)

Position Summary :

We are actively hiring Registered Nurse (RN) Clinical Appeals Specialists to join our client's growing Denial Management team. This role will have a strong focus on resolving complex clinical denials through evidence-based appeals. The Clinical Appeals Specialist will play a critical role in identifying denial trends, crafting compelling clinical arguments, and collaborating with cross-functional departments to optimize reimbursement outcomes.

Key Responsibilities :

Review, assess, and process 25+ clinical appeals per day for medical necessity, level of care, and authorization-related denials.

Draft well-supported, clinically sound appeal letters using medical documentation and payer guidelines.

Collaborate closely with Utilization Review (UR), Nursing, and Coding teams to gather essential documentation and coordinate responses.

Participate in peer-to-peer reviews with payers to support overturn of denied claims.

Analyze denial patterns and recommend process improvements to minimize future denials.

Ensure compliance with all payer timelines, regulatory standards, and internal protocols.

Maintain thorough documentation of all appeals in Epic and other relevant systems.

Required Qualifications :

Active Registered Nurse (RN) license in the state of [Insert State].

Minimum 3 years of experience working with clinical denials and appeals in a hospital or payer setting.

Strong understanding of payer policies for Medicare, Medicaid, and commercial insurers.

Exceptional written communication skills and the ability to articulate clinical reasoning in written appeals.

Familiarity with Epic and denial management workflows.

Strong organizational skills and ability to prioritize high volumes of appeals under tight deadlines.

Preferred Qualifications :

Experience participating in peer-to-peer or physician-level appeal processes.

Knowledge of utilization review and case management principles.

Ariel Greene

Project Manager

LaSalle Network