Job Description
Clinical Review & Appeals Nurse
Medix Healthcare
Tempe, AZ 85288
Monday-Friday, FULL TIME
$71,000 - 106,000 (Pay differs for an LPN)
Qualifications/Requirements
- Active and unrestricted Arizona Registered Nurse (RN) license
- 3+ years of clinical experience as an RN
- Demonstrated expertise in MS Office suite software
- Ability to independently prioritize and process a high volume of work
Essential Duties and Responsibilities:
As a Clinical Review & Appeals Specialist Nurse you will…
- Evaluate and manage appeals related to insurance denials for air ambulance transports, with a focus on medical necessity determinations.
- Work closely with clinical field teams to address documentation gaps and ensure all required materials are gathered to support appeal submissions.
- Analyze medical records and clinical documentation to assess the appropriateness and necessity of care provided.
- Coordinate with hospitals and external facilities to obtain complete and accurate medical records needed for appeal reviews.
- Collaborate with patient advocacy groups to support patients in understanding their appeal options and navigating adverse benefit decisions.
- Maintain adherence to all applicable federal, state, and payer-specific rules and requirements throughout the appeals process.
- Track and analyze denial and appeal patterns, identify improvement opportunities, and contribute to quality and process enhancement initiatives.
- Collect, organize, and submit supporting documentation for a variety of clinical and operational requests, including materials from air ambulance clinical teams.
- Complete additional responsibilities as assigned.
Work Environment: This position is going to be ON SITE.
Monday-Friday FULL TIME
$71,000 - 106,000
Job Tags
Full time, Monday to Friday,