Job Description

Clinical Review & Appeals Nurse

Medix Healthcare

Tempe, AZ 85288

Monday-Friday, FULL TIME

$71,000 - 106,000 (Pay differs for an LPN)

Qualifications/Requirements

• Active and unrestricted Arizona Registered Nurse (RN) license
• 3+ years of clinical experience as an RN
• Demonstrated expertise in MS Office suite software
• Ability to independently prioritize and process a high volume of work

Essential Duties and Responsibilities:

As a Clinical Review & Appeals Specialist Nurse you will…

• Evaluate and manage appeals related to insurance denials for air ambulance transports, with a focus on medical necessity determinations.
• Work closely with clinical field teams to address documentation gaps and ensure all required materials are gathered to support appeal submissions.
• Analyze medical records and clinical documentation to assess the appropriateness and necessity of care provided.
• Coordinate with hospitals and external facilities to obtain complete and accurate medical records needed for appeal reviews.
• Collaborate with patient advocacy groups to support patients in understanding their appeal options and navigating adverse benefit decisions.
• Maintain adherence to all applicable federal, state, and payer-specific rules and requirements throughout the appeals process.
• Track and analyze denial and appeal patterns, identify improvement opportunities, and contribute to quality and process enhancement initiatives.
• Collect, organize, and submit supporting documentation for a variety of clinical and operational requests, including materials from air ambulance clinical teams.
• Complete additional responsibilities as assigned.

Work Environment: This position is going to be ON SITE.

Monday-Friday FULL TIME

$71,000 - 106,000

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