Clinical Appeals Nurse (PRN)

About This Opportunity

We are representing a confidential healthcare organization in their search for a Clinical Appeals Nurse to join their team on a PRN basis. This remote position offers the opportunity to leverage your clinical expertise and regulatory knowledge to challenge medical necessity denials and support healthcare providers in securing appropriate reimbursement.

As part of our client's appeals team, you will review complex medical records, prepare compelling clinical arguments, and collaborate with hospital clients to overturn denials from payers and government entities. This role is ideal for an experienced RN with a strong background in acute care, case management, or utilization review who excels at written communication and analytical problem-solving.

Responsibilities

• Prepare and submit clinical appeals in response to denials from managed care organizations, governmental entities, and Recovery Audit Contractors for hospital clients
• Review medical records and utilize industry guidelines, Medicare policies, and best practice standards to support appeal arguments
• Participate in Administrative Law Judge hearings, presenting oral arguments to support the reversal of Medicare denials
• Analyze denial patterns and contribute insights to help reduce future denials
• Collaborate with the appeals team and hospital clients to provide updates on appeal statuses and outcomes
• Maintain current knowledge of healthcare regulations, coding guidelines, and payer policies relevant to the appeals process

What We're Looking For

Required:

• Bachelor's of Science in Nursing (BSN) or equivalent degree
• Current and unrestricted RN license
• At least 5 years of clinical experience in acute care settings
• At least 3 years of experience in case management, utilization review, or clinical appeals
• Exceptional written and verbal communication skills
• Proficiency with MS Office suite, particularly Word and Excel
• Strong analytical and problem-solving skills with attention to detail
• Comfortable with remote work arrangements and virtual collaboration tools

Preferred:

• Experience with payer-side case management or medical director-level review

Additional Notes:

• This is a PRN (as-needed) position based remotely in the United States
• May require occasional travel for conferences, client meetings, or in-person hearings
• Physical demands include extended periods of sitting, computer use, and telephone communication
• Candidates must be legally authorized to work in the United States; visa sponsorship is not available

How We Work With You

Our talent team at Get A Job.ai partners with you throughout the entire process. When you apply through our platform, a recruiter will screen your qualifications and experience. If there's a strong match, we will submit your profile to our client for consideration. Please note that candidates should not contact the client directly—we manage all communications to ensure a smooth and professional process.

Pay

Compensation details will be discussed during the screening process and are determined by our client based on experience and qualifications.

Equal Employment Opportunity: Get A Job.ai is committed to creating an inclusive environment for all candidates. We provide equal employment opportunities regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, or veteran status.