clinical appeals rn

CareSource

<div>
 
 Job Summary
 
 
 
 The Clinical Appeals Nurse is responsible for processing clinical appeals and attending state hearings within compliance and regulatory standards, clinical guidelines, and contractual obligations.
 
 
 
 Essential Functions
 
 
 
 <ul>
 <li>
 Responsible for the completion of clinical appeals and state hearings from all states
 </li>
 <li>
 Perform clinical reviews of member and provider appeals for medical, dental, behavioral health, pharmacy, and waiver services
 </li>
 <li>
 Analyze medical records, supporting documentation, and applicable guidelines to make informed decisions
 </li>
 <li>
 Document clinical rationale clearly and accurately in alignment with organizational and regulatory standards
 </li>
 <li>
 Work closely with medical directors, and pharmacists to resolve complex cases.
 </li>
 <li>
 Communicate outcomes effectively to members, and providers.
 </li>
 <li>
 Review and complete all provider clinical appeals within required timeframes
 </li>
 <li>
 Review and complete member clinical appeals within required timeframes
 </li>
 <li>
 Communicate with state agencies and internal departments to prepare for State Hearings
 </li>
 <li>
 Apply CareSource Medical Policy and Milliman guidelines when processing clinical appeals
 </li>
 <li>
 Issue administrative denials appropriately
 </li>
 <li>
 Refer denials based on medical necessity to medical director
 </li>
 <li>
 Collaborate with the Quality Improvement and Clinical Operations teams to prepare all requests for Independent External Review
 </li>
 <li>
 Participate in training programs to maintain clinical and regulatory expertise.
 </li>
 <li>
 Perform any other job duties as requested
 
 
 </li>
 </ul>
 
 Education And Experience
 
 
 
 <ul>
 <li>
 Associate&rsquo;s Degree required
 </li>
 <li>
 Managed care, appeals, Medicare, and Medicaid experience preferred
 </li>
 <li>
 Prior clinical appeals, and/or Utilization review experience is strongly preferred
 
 
 </li>
 </ul>
 
 Competencies, Knowledge And Skills
 
 
 
 <ul>
 <li>
 Intermediate proficiency with Microsoft Office products and Facets
 </li>
 <li>
 Knowledge of NCQA, URAC, OAC, and MDCH regulations
 </li>
 <li>
 Strong clinical judgment
 </li>
 <li>
 Attention to detail
 </li>
 <li>
 Ability to navigate complex regulations while maintaining a commitment to high-quality care
 </li>
 <li>
 Strong written and oral communication skills
 </li>
 <li>
 Ability to work independently and within a team environment
 </li>
 <li>
 Critical listening and thinking skills
 </li>
 <li>
 Proper grammar usage
 </li>
 <li>
 Time management skills
 </li>
 <li>
 Proper phone etiquette
 </li>
 <li>
 Customer Service oriented
 </li>
 <li>
 Decision making/problem solving skills
 </li>
 <li>
 Knowledge of Medicaid, and Medicare,
 </li>
 <li>
 Flexibility
 </li>
 <li>
 Change resiliency
 
 
 </li>
 </ul>
 
 Licensure And Certification
 
 
 
 <ul>
 <li>
 Current, unrestricted license as a Registered Nurse (RN) is required
 </li>
 <li>
 Multi-state RN license is preferred
 </li>
 <li>
 MCG Certification is required or must be obtained within six (6) months of hire
 
 
 </li>
 </ul>
 
 Working Conditions
 
 
 
 <ul>
 <li>
 General office environment; may be required to sit or stand for extended periods of time
 </li>
 <li>
 Position requires the flexibility to work weekends, evenings, and/or holidays, as needed
 
 
 </li>
 </ul>
 
 Compensation Range
 
 
 
 $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate&rsquo;s education, training, and experience as well as the position&rsquo;s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee&rsquo;s total well-being and offer a substantial and comprehensive total rewards package.
 
 
 
 Compensation Type
 
 
 
 Hourly
 
 
 
 Competencies
 
 
 
 <ul>
 <li>
 Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business
 
 
 </li>
 </ul>
 This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
 
 
</div>

Clinical Appeals - R11356

Elevance Health

<div>
 
 Nurse Appeals- Licensed Nurse
 
 
 
 
 Location:
 
 Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
 
 
 Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.
 
 
 
 Hours
 
 : The work schedule for this position is Tuesday through Saturday with Sunday rotation. Business hours are 8 am to 8 pm EST, and the selected candidate must be able to work an 8-hour shift between those hours, including holidays on a rotational basis.
 
 
 The
 
 Nurse Appeals
 
 is responsible for investigating and processing and medical necessity appeals requests from members and providers.
 
 
 
 How You Will Make An Impact
 
 
 
 <ul>
 <li>
 Conducts investigations and reviews of member and provider medical necessity appeals.
 </li>
 <li>
 Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
 </li>
 <li>
 Extrapolates and summarizes medical information for medical director, consultants and other external review.
 </li>
 <li>
 Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
 </li>
 <li>
 Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
 </li>
 <li>
 Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
 </li>
 <li>
 Generates written correspondence to providers, members, and regulatory entities.
 </li>
 <li>
 Utilizes leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues.
 
 
 </li>
 </ul>
 
 Minimum Requirements
 
 
 
 <ul>
 <li>
 Requires a HS diploma or equivalent and a minimum of 2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background. Current active unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
 
 
 </li>
 </ul>
 
 Preferred Skills, Capabilities And Experiences
 
 
 
 <ul>
 <li>
 AS or BS in Nursing preferred.
 </li>
 <li>
 Three to five years of clinical experience as a Registered Nurse strongly preferred.
 </li>
 <li>
 Have a current active unrestricted RN license to practice nursing within the scope of licensure in applicable state(s) or territory of the United States strongly preferred.
 </li>
 <li>
 Have two years in a managed care healthcare setting - reviewing medical records, investigation, and/or processing appeals within a managed care setting; or any combination of education and experience, which would provide an equivalent background strongly preferred.
 </li>
 <li>
 Experienced researching Medicare clinical guidelines: NCD, LCD; Medicare Benefit Policy and Milliman Care Guidelines is preferred.
 </li>
 <li>
 Experience reviewing claims and researching CPT codes or ICD-9 codes is preferred.
 </li>
 <li>
 Experience with Facets, Macess, and ACMP is preferred.
 
 
 </li>
 </ul>
 For candidates working in person or virtually in the below locations, the salary* range for this specific position is $72,492 to $108,738
 
 
 
 Locations: Latham, New York
 
 
 
 In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
 
 
 <ul>
 <li>
 The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company&rsquo;s sole discretion, consistent with the law.
 
 
 </li>
 </ul>
 Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
 
 
 Who We Are
 
 
 Elevance Health is a health company dedicated to improving lives and communities &ndash; and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
 
 
 How We Work
 
 
 At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
 
 
 We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
 
 
 Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
 
 
 The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
 
 
 Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
 
 
 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
</div>

Nurse Appeals

NORWOOD

Requirements:<ul><li>RN</li><li>One or more of the following certifications: CDIP, CCDS, CCS</li><li>ICD-10 Certification or Trainer designation highly preferred</li><li>Strong inpatient CDI experience</li><li>Proven experience writing inpatient appeal letters</li><li>Experience working with multiple payer types (DRG downgrade appeals)</li><li>Strong understanding of: (1) Clinical documentation standards, (2) Coding and reimbursement guidelines, and (3) Medical necessity criteria</li></ul>Preferred Qualifications<ul><li>Experience with denials related to post-acute or behavioral health populations</li><li>Familiarity with Cobius Manager (or similar systems)</li><li>Strong written communication skills with ability to create clear, defensible, and well-structured appeal letters</li></ul>What can you expect from your Norwood experience?<ul><li>Personalized recruiter relationships</li><li>Industry Subject Matter Experts</li><li>A sales department with reliable client relationships nationwide</li><li>Remote opportunities that allow for positive life/work balance</li><li>Permanent opportunities are available</li><li>Travel expenses are covered upfront (if travel is required)</li><li>Referral bonuses available</li><li>Full time employees enjoy 6 paid holidays, PTO and health benefits</li></ul>Applicants must be authorized to work in the US. We are unable to sponsor or take over sponsorship for any employment visas at this time.Job Types: Full-time, ContractPay: $49.00 - $51.00 per hourBenefits:<ul><li>401(k)</li><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Application Question(s):<ul><li>Do you have have a strong background in CDI and have experience with inpatient appeals letters?</li><li>Do you have CCDS, CDIP, and/or CCS Certification?</li></ul>Work Location: Remote

Appeals and Denials Nurse

Clever Care Health Plan

<div>
 Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California&rsquo;s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.
 
 
 Who Are We? ✨
 
 
 Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members&rsquo; culture and values.
 
 
 Why Join Us? 🏆
 
 
 We&rsquo;re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you&rsquo;ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.
 
 
 
 Job Summary
 
 
 
 The Clinical Review Nurse evaluates medical records and clinical documentation to support the resolution of claims, member grievances, appeals, and quality-of-care concerns. Using clinical judgment and appropriate application of CMS regulations, Medicare Advantage requirements, and evidence-based guidelines, this role conducts retrospective clinical reviews and prepares complete, accurate, and audit-ready case files for Medical Director review and determination.
 
 
 Claims are defined as:
 
 
 <ul>
 <li>
 Initial payment determinations for covered Part C and Part D services
 </li>
 <li>
 Post-service claims requiring clinical review to support payment accuracy and benefit application
 </li>
 <li>
 Claims requiring medical necessity, level-of-care, or appropriateness-of-care assessment
 </li>
 <li>
 Claims involving retrospective review of medical records or clinical documentation
 </li>
 <li>
 Provider payment disputes requiring clinical validation (non-appeal)
 </li>
 <li>
 High-dollar, complex, or high-risk claims requiring clinical review prior to final determination
 </li>
 <li>
 Claims requiring coordination with Medical Management, Claims Operations, or Medical Director review
 
 
 </li>
 </ul>
 Appeals and Grievances are defined as:
 
 
 <ul>
 <li>
 Organization Determinations / Coverage Requests (pre-service)
 </li>
 <li>
 Part C reconsiderations (standard &amp; expedited)
 </li>
 <li>
 Part D redeterminations/coverage determinations (if applicable)
 </li>
 <li>
 Payment disputes/claim appeals (if in scope)
 </li>
 <li>
 Quality of Care grievances
 </li>
 <li>
 Appeal withdrawals/dismissals &amp; validity checks (authorized rep, timeliness, etc.)
 
 
 </li>
 </ul>
 The Clinical Review Nurse applies clinical acumen to assess medical necessity, appropriateness of care, and quality of services rendered; documents findings in designated medical management systems; and collaborates with non-clinical staff to ensure timely, compliant, and defensible case resolution.
 
 
 
 Essential Functions &amp; Job Responsibilities
 
 
 
 <ul>
 <li>
 Provide clinical review support for claims, claim appeals, grievances, provider disputes, and quality of care grievances, including retrospective review of medical records and claims.
 </li>
 <li>
 Conduct clinical reviews to assess medical necessity, appropriateness of care, and quality of services rendered, using clinical judgment and applicable CMS guidelines, Medicare manuals, and plan policies.
 </li>
 <li>
 Prepare clear, concise clinical summaries and recommendations for Medical Director review, including identification of key clinical facts, regulatory considerations, and applicable coverage or clinical criteria.
 </li>
 <li>
 Support the preparation and review of Quality of Care (QOC) grievance cases for Medical Director evaluation, including identification of potential care issues, documentation gaps, and quality concerns.
 </li>
 <li>
 Apply nationally recognized clinical decision support tools and guidelines (e.g., InterQual, MCG, NCDs/LCDs, specialty society guidance) as applicable to clinical reviews.
 </li>
 <li>
 Review and interpret medical coding and billing information (CPT, HCPCS, ICD-10-CM/PCS, DRG, Revenue Codes) to support accurate clinical assessment.
 </li>
 <li>
 Identify missing or insufficient clinical documentation and coordinate with providers or internal departments to obtain additional information.
 </li>
 <li>
 Enter, maintain, and validate clinical documentation and review outcomes in medical management and case tracking systems.
 </li>
 <li>
 Ensure cases are prepared and routed within required CMS and contractual turnaround timeframes; maintain awareness of standard vs expedited timeframes and tolling requirements when records are pending.
 </li>
 <li>
 Escalates risks to prevent late determinations; escalates cases at risk of noncompliance same day when barriers arise (missing records, invalid auth rep, misrouted cases).
 </li>
 <li>
 Respond accurately and timely to Medical Directors, Claims, Appeals and Grievances staff, and other internal stakeholders regarding clinical findings.
 </li>
 <li>
 Assist with CTM-related clinical case review and provide clinical input to support compliant complaint resolution.
 </li>
 <li>
 Participate in audit readiness activities, including case file review, universe validation, and response to regulatory or oversight entity requests.
 </li>
 <li>
 Audit clinical reviews to ensure compliance with Claims, Appeals and Grievances, and medical management policies and procedures.
 </li>
 <li>
 Provide clinical guidance and act as a clinical resource to non-clinical staff.
 </li>
 <li>
 Participate in special projects related to Claims, Appeals and Grievances operations, quality improvement, or regulatory compliance.
 </li>
 <li>
 Participate in required training and assist with onboarding and education of new or existing staff as needed.
 </li>
 <li>
 Ensures all case documentation supports CMS audit and legal defensibility, including record inventory, clinical criteria citations, decision rationale, and accurate system time stamps.
 </li>
 <li>
 Differentiates and prioritizes standard vs expedited requests and applies tolling/extension rules as applicable per policy.
 </li>
 <li>
 Maintains HIPAA compliance and secure handling of PHI in all systems and remote work environments.
 </li>
 <li>
 Other duties as assigned.
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 
 Qualifications
 
 
 
 
 Education &amp; Experience
 
 
 
 <ul>
 <li>
 Graduate from an accredited school of nursing
 </li>
 <li>
 Active, unrestricted RN or LVN/LPN license
 </li>
 <li>
 Must hold a current CCS or CPC certificate; both are preferred
 </li>
 <li>
 Three (3) or more years of Appeals and Grievances and/or Utilization Management experience within a Health Plan, IPA, MSO, or managed care environment
 </li>
 <li>
 Demonstrated experience supporting Medicare Advantage Appeals and Grievances, including clinical appeal review and Medical Director case preparation
 </li>
 <li>
 Two (2) or more years of direct clinical nursing experience
 </li>
 <li>
 Knowledge of Medicare Advantage regulations related to claims, appeals, grievances, and quality of care reviews
 </li>
 <li>
 Experience applying clinical decision support tools (e.g., InterQual, MCG, NCDs/LCDs) and evidence-based guidelines
 </li>
 <li>
 Familiarity with medical coding and billing concepts (CPT, HCPCS, ICD-10, DRG, Revenue Codes)
 </li>
 <li>
 Knowledge of regulatory timelines to ensure compliance with CMS and state requirements
 
 
 </li>
 </ul>
 
 Skills
 
 
 
 <ul>
 <li>
 Strong clinical judgment and analytical skills
 </li>
 <li>
 Strong organizational skills with the ability to manage multiple cases and deadlines
 </li>
 <li>
 Excellent written and verbal communication skills, including clinical summary preparation
 </li>
 <li>
 Strong attention to detail and documentation accuracy
 </li>
 <li>
 Proficiency with Windows-based applications and Microsoft Office (Word, Excel, PowerPoint)
 </li>
 <li>
 Ability to adapt to new systems and regulatory requirements
 </li>
 <li>
 Excellent typing and documentation skills
 
 
 </li>
 </ul>
 
 Wage Range:
 
 $38.46 to $48.00 per hour DOE and License
 
 
 
 Physical &amp; Working Environment.
 
 
 
 Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:
 
 
 <ul>
 <li>
 Must be able to travel when needed or required
 </li>
 <li>
 Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (notetaking)
 </li>
 <li>
 Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.
 
 
 </li>
 </ul>
 Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.
 
 
 Work is performed in an office environment and/or remotely. When working remotely, the workspace must be HIPAA compliant:
 
 
 <ul>
 <li>
 HIPAA/PHI handling, minimum necessary access
 </li>
 <li>
 Secure remote work expectations (private workspace, locking screens, secure network, no printing unless authorized, etc.)
 
 
 </li>
 </ul>
 The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.
 
 
 
 Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.
 
 
 
 
 Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate&rsquo;s state residency.
 
</div>

Grievance and Appeals Clinical Review Nurse (RN/LVN)

Toney HealthCare Consulting, LLC

The Supervisor, Utilization Management &amp; Appeals is responsible for overseeing daily Utilization Management (UM) and Appeals operations while also providing hands-on overnight, weekend and holiday coverage. This role combines clinical leadership with operational execution to ensure timely, accurate, and compliant utilization and appeal workflows. The Supervisor provides guidance and oversight to UM nurses, supports complex case preparation, ensures regulatory compliance, and maintains operational continuity.This position plays a critical role in ensuring high-quality clinical documentation, effective workload management, and coordination with medical directors, providers, and internal stakeholders.Essential Functions / Key ResponsibilitiesLeadership &amp; Operations<ul><li>Supervise daily activities of UM and Appeals staff, including nurses.</li><li>Monitor workloads, productivity, and performance metrics to maintain service-level and regulatory compliance.</li><li>Provide clinical oversight and coaching on complex UM and Appeals cases; escalate to medical directors as appropriate.</li><li>Train, mentor, and evaluate team members; participate in hiring, corrective action, and performance management processes.</li><li>Develop, implement, and maintain standard operating procedures (SOPs) across UM and Appeals workflows.</li><li>Participate in audits, reporting, and continuous performance improvement initiatives.</li><li>Collaborate cross-functionally with medical directors, case management, providers, and client stakeholders to ensure appropriate care and avoid unnecessary utilization.</li></ul>Clinical &amp; Overnight Coverage<ul><li>Provide overnight, weekend, and holiday operational coverage to maintain continuous UM and Appeals workflows.</li><li>Manage and process work queues, including screening requests, creating authorizations, routing cases, and generating member and provider notifications.</li><li>Prepare accurate and thorough clinical summaries and documentation for physician review (non-decisional).</li><li>Review case data for completeness, accuracy, and regulatory alignment prior to submission.</li><li>Support Appeals intake, screening, and case preparation in accordance with appeal protocols.</li><li>Work independently during overnight and weekend hours with minimal supervision, maintaining productivity during low call-volume periods through assigned tasks.</li></ul>Compliance &amp; Knowledge Management<ul><li>Ensure adherence to federal and state regulations, NCQA/URAC standards, and payer-specific UM and Appeals requirements.</li><li>Maintain strong working knowledge of InterQual and/or MCG criteria.</li><li>Stay current on healthcare regulations, utilization trends, and evidence-based clinical guidelines.</li><li>Ensure consistent application of UM and Appeals policies across all shifts.</li></ul>Core Competencies<ul><li>Leads by example; fosters accountability, trust, and team engagement.</li><li>Thrives in fast-paced, evolving environments and adapts quickly to changing client needs.</li><li>Applies strong clinical judgment and analytical reasoning.</li><li>Anticipates operational challenges, investigates root causes, and implements solutions.</li><li>Communicates effectively with clinical, operational, and client-facing stakeholders.</li><li>Champions operational efficiency and service excellence.</li><li>Provides ongoing feedback, mentorship, and professional development.</li></ul>Required Education &amp; Experience<ul><li>Active, unrestricted Registered Nurse (RN) license in California.</li><li>Minimum of 5 years of Utilization Management experience and 2 years of Appeals experience.</li><li>At least 2 years of leadership or supervisory experience in a UM or Appeals setting.</li><li>Strong understanding of UM and Appeals processes, including intake, screening, and documentation.</li><li>Experience managing or supporting remote clinical teams.</li><li>Familiarity with Medicare, Medicaid, and commercial payer requirements.</li><li>Excellent written communication, attention to detail, and organizational skills.</li><li>Ability to work independently during overnight and weekend shifts.</li></ul>Preferred Qualifications<ul><li>Bachelor of Science in Nursing (BSN).</li><li>Consulting or project-based healthcare experience.</li></ul>Work Schedule<ul><li>Day and overnight coverage, including:</li><li>Weekdays: 5:00 PM &ndash; 8:00 AM (PT)</li><li>Weekends: 8:00 AM Saturday &ndash; 8:00 AM Monday (PT)</li><li>Required holidays and on-call rotation.</li></ul>Physical Requirements / Work Environment<ul><li>Fully remote role with occasional travel (less than 5%).</li><li>Must maintain a secure home office environment with required equipment.</li><li>Prolonged periods of sitting and computer use.</li><li>Ability to communicate clearly in both written and verbal formats.</li></ul>Pay: $50.00 - $60.00 per hourBenefits:<ul><li>401(k)</li><li>Dental insurance</li><li>Health insurance</li><li>Life insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Experience:<ul><li>Utilization management: 5 years (Required)</li><li>Appeals: 2 years (Required)</li><li>UM leadership : 2 years (Preferred)</li></ul>License/Certification:<ul><li>RN license in California? (Required)</li></ul>Shift availability:<ul><li>Day Shift (Required)</li><li>Night Shift (Required)</li><li>Overnight Shift (Required)</li></ul>Work Location: Remote

Supervisor, Utilization Management & Appeals (After-Hours/Overnight)

ACMH Hospital

<div><div><div><div><div>Job Type:</div> <div>Full Time</div>
</div> 
<div><div>Department:</div> <div>Administration</div>
</div> 
</div></div>Description:
<div>Daylight: 7:00am-3:30pm
REQUIRED:
Current RN license with 3-5 years acute nursing experience
Strong knowledge of sepsis pathophysiology &amp; management
Demonstrated experience with clinical documentation review
&amp; management
Ability to apply clinical judgement to documentation, qualify
&amp; payer requirements 

PREFERRED:
CDI certification (CDIP, CCDS, CCDs-0) or willingness to obtain
Within a defined timeframe preferred
Sepsis abstraction or quality experience preferred
Experience with payer audits, denials or appeals
rushk@acmh.org</div></div>

Clinical Documentation Specialist - Sepsis Coordinator

Bristol Hospice

<div>Are you an experienced RN or LPN with a strong background in hospice documentation, audits, and compliance? We&rsquo;re looking for a detail-oriented, solutions-driven nursing professional who is passionate about ensuring quality care and protecting reimbursement through accurate documentation and timely appeals.
As the National Appeals and Denials Manager, you&rsquo;ll play a vital role at the intersection of clinical operations, compliance, and billing. Reporting to the Regional Vice President of Clinical Operations, you&rsquo;ll lead efforts to respond to medical record requests, manage appeals, analyze denial trends, and collaborate with cross-functional teams to support regulatory readiness and operational excellence.
Bristol Hospice is a nationwide industry leader committed to providing a family-centered approach in the delivery of hospice services throughout our communities. We are dedicated to our mission that all patients and families entrusted to our care will be treated with the highest level of compassion, respect, and dignity. For more information about Bristol Hospice, visit bristolhospice.com or follow us on LinkedIn.
Our Culture
Our culture is cultivated using the following values:<ul><li>
Integrity: We are honest and professional.</li><li>
Trust: We count on each other.</li><li>
Excellence: We strive to always do our best and look for ways to improve and excel.</li><li>
Accountability: We accept responsibility for our actions, attitudes, and mistakes.</li><li>
Mutual Respect: We treat others the way we want to be treated.</li></ul>
On an Average Day You Will:
(includes but not limited to)<ul><li>
Review and respond to ADRs from Medicare, Medicaid, and other regulatory entities (TPE, SMRC, UPIC, ZPIC, OIG)</li><li>
Track and monitor records requests in systems such as Waystar, NGS, CGS, Palmetto, and Quantum</li><li>
Collaborate with local teams to gather and validate documentation for appeals and audits</li><li>
Analyze denial trends and provide insights to leadership for targeted education and process improvement</li><li>
Prepare, submit, and follow up on appeals in coordination with clinical and billing teams</li><li>
Ensure all appeal and record request deadlines are met with complete and accurate submissions</li><li>
Partner with billing, informatics, and regional leaders to ensure data accuracy and transparency</li><li>
Communicate regularly with cross-functional teams to identify and resolve compliance or documentation gaps</li><li>
Contribute to continuous improvement efforts through QAPI and staff education</li><li>
Support organizational compliance through policy implementation and proactive issue identification</li><li>
Conduct annual evaluations for direct reports and provide ongoing performance feedback</li><li>
Maintain open communication through team meetings, email, and real-time messaging</li><li>
All other duties as assigned</li></ul>
Requirements:
<ul><li>Active RN or LPN license required.
</li><li>Minimum 5 years of nursing experience</li><li>
At least 1 year of hospice experience required</li><li>
Hospice administrative experience strongly preferred</li></ul>
Our Ideal Candidate Has the Following Skills and Knowledge:
<ul><li>In-depth understanding of federal, state, and accreditation standards specific to hospice care</li><li>
Strong working knowledge of the appeals and denials process, including experience with TPE, SMRC, UPIC, ZPIC, OIG, Medicaid, and Medicare Advantage audits</li><li>
Proven ability to analyze denial trends and translate findings into actionable education and process improvement</li><li>
Proficiency in tracking systems and payer portals such as Waystar, NGS, CGS, Palmetto, and Quantum</li><li>
Clear and professional verbal and written communication skills</li><li>
Strong attention to detail and accuracy in documentation and reporting</li><li>
Ability to lead, collaborate, and build effective working relationships with cross-functional teams</li><li>
Adaptability to shifting priorities and deadlines in a fast-paced, compliance-driven environment</li><li>
Experience with staff training, development, and performance evaluation</li><li>
Commitment to ethical standards, patient confidentiality, and organizational transparency</li></ul>
We Got the Perks:
<ul><li>Tuition Reimbursement</li><li>
PTO and Paid Holidays</li><li>
Medical, Dental, Vision, Life Insurance, and more</li><li>
HSA &amp; 401(k) available</li><li>
Mileage Reimbursement for applicable positions</li><li>
Advanced training programs</li><li>
Passionate company culture committed to the highest standard of care in the hospice industry</li></ul>
Join a Team that embraces the reverence of life!
EEOC Statement
Bristol Hospice is an equal-opportunity employer. Our success depends upon our ability to create and maintain a diverse and supportive work environment where individuality is promoted. Bristol puts high priority on the worth of every person. We do not base our hiring decisions on race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics</div>

National Appeals and Denials Manager

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