Clinical Appeals Nurse (PRN)

Location: Remote - Other. Applicants must be legally authorized to work in the United States. Occasional travel may be required for conferences, client meetings, or in-person hearings.

Company

hirify.global provides healthcare technology and services for healthcare organizations.

What you will do

• Prepare and submit clinical appeals addressing medical necessity denials and DRG reassignments from managed care organizations, government entities, and Recovery Audit Contractors.
• Review medical records and apply industry guidelines, Medicare policies, and best-practice standards to develop appeal arguments.
• Participate in Administrative Law Judge hearings and present oral arguments supporting the reversal of Medicare denials.
• Analyze denial patterns and provide insights to help reduce future denials.
• Collaborate with the appeals team and hospital clients on appeal status and outcomes.
• Maintain current knowledge of healthcare regulations, coding guidelines, and payer policies.

Requirements

• United States work authorization is required; visa sponsorship is not available.
• Bachelor of Science in Nursing or an equivalent degree.
• Current and unrestricted registered nurse license.
• At least five years of clinical experience in acute care settings.
• At least three years of experience in case management, utilization review, or clinical appeals.
• Strong written and verbal communication, analytical, problem-solving, and attention-to-detail skills, with proficiency in Microsoft Word and Excel.

Nice to have

• Experience with payer-side case management or medical director-level review.

Culture & Benefits

• Part-time remote work with virtual collaboration.
• Occasional travel may be required for conferences, client meetings, or in-person hearings.
• The role involves extended periods of sitting, computer use, and telephone communication.
• Employment is subject to a post-offer background check and drug screen.
• Equal opportunity and affirmative action workplace committed to an inclusive environment.