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Clinical Appeal Jobs (NOW HIRING)

Vivian Health

Denial and Appeals RN in Bristol, CT

Bristol, CT · On-site

$22 - $27.25/hr

Partner with the Medical Director and Physician Advisor staff to compose factually sound appeal letters for denial reconsiderations utilizing clinical documentation and contract language * Maintain ...

Vivian Health

Denial and Appeals RN in Avon, CT

Avon, CT · On-site

$21.75 - $26.75/hr

Partner with the Medical Director and Physician Advisor staff to compose factually sound appeal letters for denial reconsiderations utilizing clinical documentation and contract language * Maintain ...

Vivian Health

Denial and Appeals RN in Durham, CT

Durham, CT · On-site

$21.50 - $26.50/hr

Partner with the Medical Director and Physician Advisor staff to compose factually sound appeal letters for denial reconsiderations utilizing clinical documentation and contract language * Maintain ...

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How much do clinical appeal jobs pay per year?

As of Sep 12, 2026, the average yearly pay for clinical appeal in the United States is $69,454.00, according to ZipRecruiter salary data. Most workers in this role earn between $45,000.00 and $83,000.00 per year, depending on experience, location, and employer.

UTILIZATION REVIEW AND APPEALS RN

Carson City, NV • On-site

Carson Tahoe Health
See more jobs at Carson Tahoe Healthexternal

Full-time

Re-posted yesterday

Key responsibilities

  • Screen for accurate medical necessity and respond to authorization concerns using approved criteria and supporting documentation.

  • Draft, finalize, and send clinical appeal letters to reverse insurance denials and develop documented responses to overturn payer decisions.

  • Collaborate with medical staff, interdisciplinary team, and external resources to coordinate care, promote patient throughput, and ensure appropriate utilization of resources.

Carson Tahoe Health rating

7.9

Company rating: 7.9 out of 10

Based on 10 frontline employees who took The Breakroom Quiz

Job description

US:NV:Carson City Case Management
Full Time Day Shift
Summary
This position is responsible for facilitating care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources while respecting patient's right to self-determination. This position has the overall responsibility to maintain current knowledge of disease processes, available resources, treatment options appropriate to patient population and reviewing medical necessity, responding to authorization concerns, and/or reconciling coverage related issues. This position collaborates with medical staff, interdisciplinary team, and external resources to screen for accurate medical necessity and appeal appropriate accounts according to internal guidelines.
Qualifications
Required:
  • Minimum (2) years of acute care hospital patient care experience
  • Current unrestricted registered nurse license in the State of Nevada
  • Organizational skills, excellent verbal & written communication skills, ability to lead, coordinate diverse group in fast paced environment, critical thinking, problem solving and negotiation skills

Preferred:
  • Two (2) years of experience as acute care case manager
  • Bachelor of Science in Nursing
  • Ability to obtain Accredited Case Manager (ACM) certification

Essential Functions
  • Transition management - Assigns appropriate length of stay, participates in readmission prevention, transition level of care and patient satisfaction
  • Utilization management - Screens for accurate medical necessity using approved evidenced based criteria, application of supporting medical necessity and denial prevention utilizing physician advisor when necessary
  • Reviews clinical denials and initiates process, if determined appeal appropriate according to internal guidelines
  • Clinical Appeals - Responsible for drafting, finalizing, and sending clinical appeal letters in order to reverse a denial for payment on an insurance claim
  • Uses provided tools and patient medical records, working within and through the regulations to develop a documented response to the denial and overturn the payer's decision
  • Stays current with assigned accounts and follow-up on the appeal after submission to determine next steps to ensure appeals are overturned or upheld
  • Responsible for appealing denials using clinical based rationale, the need to produce high quality work with meeting compliance timeframes and production goals
  • Supports billing and authorization coordination staff in reviewing high-risk and high-dollar accounts before claim submission to prevent clinical denial
  • Works in partnership with Integrated Care Management Authorization Coordinators and Admin Staff
  • Assists staff in care coordination and demonstrates efficient throughput while assuring care is sequenced and at appropriate level of care
  • Accurately conducts a thorough, objective assessment of patient's current status, including psychosocial, physical, financial, educational needs, treatment course and services needed
  • Compliance with state and federal regulations, The Joint Commission's standards, Center for Improvement in Healthcare Quality (CIHQ), Conditions of Participation and hospital policy
  • Maintains current knowledge of disease processes, available resources, and treatment options appropriate to patient population
  • Collaborates with interdisciplinary team to promote patient throughput and efficient use of resources
  • Continuously demonstrates a positive attitude and understanding of case management philosophy, supports team building, and is motivated to fulfill department objectives
  • Utilizes Evidence -based clinical guideline tool (Milliman Care Guidelines ® or InterQual ®)
  • Documents all activity according to policy, including the electronic automated systems
  • Precepts new staff members and is a resource to all staff
  • Participates in department quality improvement initiatives and projects as assigned
  • Ability to perform role remotely and maintain collaboration with interdisciplinary team
  • Performs other related duties as assigned

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