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Appeals And Denials Jobs (NOW HIRING)

Guidehouse

Clinical Appeals/Denials RN

$74K - $124K/yr

Prior experience in clinical denials, utilization review, case management, or appeals required What Would Be Nice To Have : * Bachelor of Science in Nursing * Master's degree in Nursing * Experience ...

Northwell

Appeals Specialist

Lake Success, NY · On-site

$66K - $108K/yr

Responds to commercial payers, managed care and third party review organizations in managing the appeals/denials process. Supports the review of denial trends and identifies coding issues and ...

Northwell Health

Appeals Specialist

Lake Success, NY · On-site

$66K - $108K/yr

Responds to commercial payers, managed care and third party review organizations in managing the appeals/denials process. Supports the review of denial trends and identifies coding issues and ...

Northwell

Appeals Specialist

Lake Success, NY · On-site

Responds to commercial payers, managed care and third party review organizations in managing the appeals/denials process. Supports the review of denial trends and identifies coding issues and ...

West Virginia University Health System

Coordinates and performs appeals writing for RAC, Medicaid RAC, payer and other government denials. Provide process improvement initiatives through route cause analysis. MINIMUM QUALIFICATIONS:

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$30.5K

$86.5K

$115.5K

How much do appeals and denials jobs pay per year?

As of Aug 9, 2026, the average yearly pay for appeals and denials in the United States is $86,480.00, according to ZipRecruiter salary data. Most workers in this role earn between $66,500.00 and $98,500.00 per year, depending on experience, location, and employer.

What is the difference between Appeals And Denials vs Claims Processor?

AspectAppeals And DenialsClaims Processor
Primary RoleReviewing and contesting denied insurance claimsProcessing and entering insurance claims for payment
Required CredentialsKnowledge of insurance policies, healthcare regulationsBasic insurance and data entry skills
Work EnvironmentHealthcare offices, insurance companiesMedical offices, insurance companies

Appeals And Denials specialists focus on challenging denied claims, requiring detailed knowledge of policies and regulations. Claims Processors handle the initial processing of claims, ensuring accurate data entry and submission. While both roles work within the insurance industry, Appeals And Denials professionals deal with complex disputes, whereas Claims Processors manage routine claim processing tasks.

What are appeals and denials?

Appeals and Denials refer to the process within healthcare billing and insurance where claims for medical services are either rejected (denied) or challenged (appealed) by providers or patients. Denials occur when an insurance company refuses to pay for a service, often due to issues like lack of coverage, missing documentation, or coding errors. Appeals happen when a provider or patient disagrees with the denial and formally requests a review or reconsideration. This process is crucial for ensuring that providers receive appropriate payment and that patients have access to necessary care. Understanding the appeals and denials process helps reduce lost revenue and improves patient satisfaction.

What skills do you need to be an appeals and denials specialist?

An appeals and denials specialist needs strong attention to detail, excellent communication skills, and knowledge of insurance policies and billing procedures. Proficiency with electronic health record systems and claim management software is also important, along with the ability to analyze and interpret complex information efficiently.

What are common challenges faced in an appeals and denials specialist role, and how can they be effectively managed?

Appeals and Denials Specialists often face challenges such as navigating complex insurance policies, meeting tight deadlines for appeal submissions, and ensuring thorough documentation for each case. Staying organized and detail-oriented is crucial, as missing a deadline or required document can result in lost reimbursement. Effective communication with insurance companies, healthcare providers, and internal teams helps streamline the process and resolve denials more efficiently. Leveraging standardized templates and keeping up with regulatory changes also contribute to success in this role.

What are the key skills and qualifications needed to thrive as an appeals and denials specialist, and why are they important?

To thrive as an Appeals and Denials Specialist, you need a strong understanding of medical billing, insurance policies, and claims processing, typically supported by experience in healthcare administration or a related field. Familiarity with claims management software, electronic health records (EHRs), and knowledge of HIPAA regulations are essential technical requirements. Excellent analytical skills, attention to detail, and effective written and verbal communication are soft skills that set top performers apart. These skills and qualifications are crucial for successfully resolving complex claims issues, maximizing reimbursement, and ensuring compliance with payer requirements.
More about Appeals And Denials jobs
What cities are hiring for Appeals And Denials jobs? Cities with the most Appeals And Denials job openings:
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What job categories do people searching Appeals And Denials jobs look for? The top searched job categories for Appeals And Denials jobs are:
Appeals And Denials jobs near you
Infographic showing various Appeals And Denials job openings in the United States as of August 2026, with employment types broken down into 90% Full Time, 8% Part Time, and 2% Contract. Highlights an 81% Physical, 6% Hybrid, and 13% Remote job distribution, with an average salary of $86,480 per year, or $41.6 per hour.

Clinical Appeals/Denials RN

Guidehouse

Remote

$74K - $124K/yr

Full-time

Medical, Dental, Vision, Life, Retirement

Posted 9 days ago

Guidehouse rating

7.7

Company rating: 7.7 out of 10

Based on 27 frontline employees who took The Breakroom Quiz

42nd of 72 rated business consultants

Job description

Job Family:
Clinical Appeals Nurse
Travel Required:
None
Clearance Required:
None
What You Will Do:
  • Conduct pre- and post-service medical necessity reviews for inpatient, observation, and outpatient hospital encounters using evidence-based criteria such as InterQual and Milliman Care Guidelines.
  • Perform retrospective medical record reviews to validate completeness and accuracy of physician and clinical documentation supporting level of care and services rendered.
  • Identify denial root causes and determine appeal viability based on payer policies, regulatory guidance, and clinical standards.
  • Prepare, submit, and track clinical appeals, including written appeals.
  • Collaborate with Patient Access, Case Management, Utilization Management, Coding, and Mid-Revenue Cycle teams to resolve denials and prevent recurrence.
  • Research and apply payer-specific policies, CMS regulations, and contractual language to support appeal arguments.
  • Track and report denial and appeal outcomes, identify trends, and provide recommendations for process improvement and staff education.
  • Maintain accurate documentation of all review activities in hospital and payer systems in accordance with compliance standards.

What You Will Need:
  • Current unrestricted Registered Nurse license in the state you reside.
  • Requires a University Degree and minimum 4-6 years of prior relevant experience in acute care clinical experience in hospital setting (Relevant experience may be substituted for formal education or advanced degree)
  • Prior experience in clinical denials, utilization review, case management, or appeals required

What Would Be Nice To Have:
  • Bachelor of Science in Nursing
  • Master's degree in Nursing
  • Experience with InterQual and/or Milliman Care Guidelines, and electronic medical record systems.
  • Compact State RN License
  • Experience with inpatient level-of-care denials, DRG downgrades, and CMS payer rules.
  • Strong knowledge of hospital revenue cycle workflows, medical necessity review, and payer regulations.
  • Excellent analytical, organizational, and written communication skills with the ability to independently manage multiple cases.

The annual salary range for this position is $74,000.00-$124,000.00. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, experience and training, security clearances, licensure and certifications, and other business and organizational needs.
What We Offer:
Guidehouse offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.
Benefits include:
  • Medical, Rx, Dental & Vision Insurance
  • Personal and Family Sick Time & Company Paid Holidays
  • Position may be eligible for a discretionary variable incentive bonus
  • Parental Leave
  • 401(k) Retirement Plan
  • Basic Life & Supplemental Life
  • Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
  • Short-Term & Long-Term Disability
  • Tuition Reimbursement, Personal Development & Learning Opportunities
  • Skills Development & Certifications
  • Employee Referral Program
  • Corporate Sponsored Events & Community Outreach
  • Emergency Back-Up Childcare Program

About Guidehouse
Guidehouse is an Equal Opportunity Employer-Protected Veterans, Individuals with Disabilities or any other basis protected by law, ordinance, or regulation.
Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.
If you have visited our website for information about employment opportunities, or to apply for a position, and you require an accommodation, please contact Guidehouse Recruiting at 1-571-633-1711 or via email at RecruitingAccommodation@guidehouse.com. All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation.
All communication regarding recruitment for a Guidehouse position will be sent from Guidehouse email domains including @guidehouse.com or guidehouse@myworkday.com. Correspondence received by an applicant from any other domain should be considered unauthorized and will not be honored by Guidehouse. Note that Guidehouse will never charge a fee or require a money transfer at any stage of the recruitment process and does not collect fees from educational institutions for participation in a recruitment event. Never provide your banking information to a third party purporting to need that information to proceed in the hiring process.
If any person or organization demands money related to a job opportunity with Guidehouse, please report the matter to Guidehouse's Ethics Hotline. If you want to check the validity of correspondence you have received, please contact recruiting@guidehouse.com. Guidehouse is not responsible for losses incurred (monetary or otherwise) from an applicant's dealings with unauthorized third parties.
Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee.

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