RN Clinical Appeals Specialist

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.