Clinical Appeals Nurse

R1 is the leading provider of technology-driven solutions that transform the patient experience and financial performance of hospitals, health systems, and medical groups. We are the one company that combines the deep expertise of a global workforce of revenue cycle professionals with the industry’s most advanced technology platform, encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration. 

As our Clinical Appeals Nurse, you will help our hospital clients by serving as an expert on appeals and denials management where claims were denied by either governmental contractors or commercial payers.  Every day you will thoroughly review patient clinical and hospital course documentation, as well as payer policy and denial information.  Once reviewed, then you will prepare an appropriate written document and represent client hospitals during hearings if needed. 

To thrive in this role, you must have experience in a clinical inpatient environment working with a wide range of patient populations, and the ability to use sound judgment in reviewing clinical documentation supporting patient care as well as conceptual knowledge of the denials landscape.  Proficiency in basic computer skills is essential for excelling in this remote, production-driven position.

Here’s what you will experience working as a Clinical Appeals Nurse:

• Conduct a detailed review of patient medical records and payer denial information submitted by clients to assess the entire hospital stay and clinical course of the patient.
• Identify risk factors, comorbidities, and adverse events to determine if payer denial was justified for that hospital stay or service using evidence-based guidelines.
• Review governmental regulations, payer protocols, and/or medical policy to recommend appropriate actions.
• Apply clinical judgment to support medical necessity appeals reviewing against appropriate coverage guidelines.
• Leverage proficient writing skills to prepare written appeals.  Represent clients at telephonic hearings if needed.

Required Skills:

• Active Registered Nurse license

The healthcare system is always evolving — and it’s up to us to use our shared expertise to find new solutions that can keep up. On our growing team you’ll find the opportunity to constantly learn, collaborate across groups and explore new paths for your career.

Our associates are given the chance to contribute, think boldly and create meaningful work that makes a difference in the communities we serve around the world. We go beyond expectations in everything we do. Not only does that drive customer success and improve patient care, but that same enthusiasm is applied to giving back to the community and taking care of our team — including offering a competitive benefits package.

R1 RCM Inc. (“the Company”) is dedicated to the fundamentals of equal employment opportunity. The Company’s employment practices , including those regarding recruitment, hiring, assignment, promotion, compensation, benefits, training, discipline, and termination shall not be based on any person’s age, color, national origin, citizenship status, physical or mental disability, medical condition, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status or any other characteristic protected by federal, state or local law. Furthermore, the Company is dedicated to providing a workplace free from harassment based on any of the foregoing protected categories.

If you have a disability and require a reasonable accommodation to complete any part of the job application process, please contact us at 312-496-7709 for assistance.

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To learn more, visit: R1RCM.com

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