Conifer Health Solutions
Clinical Appeal Nurse - Remote - $10K Sign On Bonus
Conifer Health Solutions, Frisco, Texas, United States, 75034
Clinical Appeal Nurse - Remote - $10K Sign On Bonus
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Clinical Appeal Nurse - Remote - $10K Sign On Bonus
role at
Conifer Health Solutions
Job Summary The Revenue Cycle Clinician for the Appellate Solution is responsible for recovering revenue associated with disputed or denied clinical claims and preparing and documenting appeal based on industry accepted criteria.
Essential Duties and Responsibilities
Perform post‑discharge medical necessity reviews to determine appellate potential of clinical disputes or denied claims.
Utilize InterQual® criteria, construct and document a concise clinical case to support appeal.
Follow documented processes for supporting the clinical appellate process.
Adhere to productivity and quality goals, ensuring timely work per payer guidelines.
Utilize electronic tools (ACE, nThrive, eCARE, InterQual®, etc.) and Microsoft Office.
Apply basic patient accounting knowledge (UB92/UB04, EOB components, denials management).
Serve as a resource to non‑clinical personnel and provide process improvement solutions.
Assist in policy development and support the Law Department with medical necessity reviews and mediation hearings.
Knowledge, Skills, and Abilities
Proficiency in InterQual® and medical necessity criteria.
Excellent written, verbal, and professional letter writing skills.
Critical thinker with independent decision‑making on medical necessity.
Professional interaction with clinical and non‑clinical partners.
Knowledge of managed care contracts and reimbursement matrixes.
Multi‑tasking ability and research skills on state/federal appellate guidelines.
Research knowledge of off‑label medication uses.
Education and Experience
Valid RN license (Registered).
Minimum of 3 years recent acute care experience in a facility environment.
Medical‑surgical/critical care experience preferred.
Minimum 2 years case management or utilization review experience preferred.
Managed care payer experience preferred.
Previous classroom instruction on InterQual® products preferred.
Certificates, Licenses, and Registrations
Current valid RN licensure (required).
Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR, CPUM, or CPHM) preferred.
Physical Demands
Ability to lift 15–20 lbs.
Travel up to 10% of the time to facility or national sites.
Ability to sit and work at a computer for prolonged periods.
Work Environment
Typical office environment with desk, chair, computer, telephone, printer.
Compensation and Benefits
Pay: $30.85 – $46.28 per hour.
Sign‑on bonus may be offered to qualified new hires.
Paid holidays (time and a half).
Benefits include medical, dental, vision, disability, life insurance, paid time off, 401(k) with 6% match, health savings accounts, employee assistance program, and voluntary benefits.
Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex, national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status, or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
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Clinical Appeal Nurse - Remote - $10K Sign On Bonus
role at
Conifer Health Solutions
Job Summary The Revenue Cycle Clinician for the Appellate Solution is responsible for recovering revenue associated with disputed or denied clinical claims and preparing and documenting appeal based on industry accepted criteria.
Essential Duties and Responsibilities
Perform post‑discharge medical necessity reviews to determine appellate potential of clinical disputes or denied claims.
Utilize InterQual® criteria, construct and document a concise clinical case to support appeal.
Follow documented processes for supporting the clinical appellate process.
Adhere to productivity and quality goals, ensuring timely work per payer guidelines.
Utilize electronic tools (ACE, nThrive, eCARE, InterQual®, etc.) and Microsoft Office.
Apply basic patient accounting knowledge (UB92/UB04, EOB components, denials management).
Serve as a resource to non‑clinical personnel and provide process improvement solutions.
Assist in policy development and support the Law Department with medical necessity reviews and mediation hearings.
Knowledge, Skills, and Abilities
Proficiency in InterQual® and medical necessity criteria.
Excellent written, verbal, and professional letter writing skills.
Critical thinker with independent decision‑making on medical necessity.
Professional interaction with clinical and non‑clinical partners.
Knowledge of managed care contracts and reimbursement matrixes.
Multi‑tasking ability and research skills on state/federal appellate guidelines.
Research knowledge of off‑label medication uses.
Education and Experience
Valid RN license (Registered).
Minimum of 3 years recent acute care experience in a facility environment.
Medical‑surgical/critical care experience preferred.
Minimum 2 years case management or utilization review experience preferred.
Managed care payer experience preferred.
Previous classroom instruction on InterQual® products preferred.
Certificates, Licenses, and Registrations
Current valid RN licensure (required).
Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR, CPUM, or CPHM) preferred.
Physical Demands
Ability to lift 15–20 lbs.
Travel up to 10% of the time to facility or national sites.
Ability to sit and work at a computer for prolonged periods.
Work Environment
Typical office environment with desk, chair, computer, telephone, printer.
Compensation and Benefits
Pay: $30.85 – $46.28 per hour.
Sign‑on bonus may be offered to qualified new hires.
Paid holidays (time and a half).
Benefits include medical, dental, vision, disability, life insurance, paid time off, 401(k) with 6% match, health savings accounts, employee assistance program, and voluntary benefits.
Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex, national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status, or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
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