Clinical Appeals Nurse

Netsmart

Clinical Appeals Nurse preparing medical necessity and Medicare denial appeals for Netsmart’s hospital clients. Reviewing records, supporting ALJ hearings, and analyzing denial patterns remotely.

Posted 8/4/2026part-timeRemote • 🇺🇸 United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical appeals, including preparation and submission to managed care organizations and governmental entities, while maintaining knowledge of healthcare regulations and coding guidelines. Strong analytical skills are essential for analyzing denial patterns and providing insights to reduce future denials.

Highest-signal resume keywords

Clinical Appeals PreparationCase Management ExperienceAcute Care Clinical ExperienceRN LicenseHealthcare Regulations Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AppealsDenial AnalysisUtilization ReviewMedical Record ReviewOral Argument PresentationAttention to DetailAnalytical Skills

Soft Skills

Written CommunicationVerbal CommunicationProblem-SolvingCollaboration

Tools & Technologies

Microsoft Office SuiteWordExcelVirtual Collaboration Tools

Certifications & Qualifications

Bachelor's of Science in Nursing (BSN)Current RN License

Industry Keywords

Healthcare RegulationsMedicare PoliciesBest Practice StandardsManaged Care OrganizationsRecovery Audit Contractors

About the role

Key responsibilities & impact

Review medical records and prepare clinical appeals in response to medical necessity denials and DRG reassignments
Prepare and submit clinical appeals to managed care organizations, governmental entities, and Recovery Audit Contractors for hospital clients
Use industry guidelines, Medicare policies, and best practice standards to support appeal arguments
Participate in Administrative Law Judge hearings and present oral arguments supporting reversal of Medicare denials
Analyze denial patterns and provide insights to reduce future denials
Collaborate with the appeals team and hospital clients on appeal statuses and outcomes
Maintain current knowledge of healthcare regulations, coding guidelines, and payer policies relevant to appeals

Requirements

What you’ll need

Bachelor's of Science in Nursing (BSN) or equivalent degree
Current and unrestricted RN license
At least 5 years of clinical experience in acute care settings
At least 3 years of experience in case management, utilization review, or clinical appeals
Exceptional written and verbal communication skills
Proficiency with Microsoft Office Suite, particularly Word and Excel
Strong analytical and problem-solving skills with attention to detail
Comfortable with remote work arrangements and virtual collaboration tools
Must successfully complete a pre-employment background check, including a drug screen
Must be legally authorized to work in the United States
Netsmart does not provide work visa sponsorship

Benefits

Comp & perks

Part-time employment
Fully remote work arrangement
Occasional travel for conferences, client meetings, or in-person hearings
Pre-employment background check and drug screen provided at Netsmart’s sole expense