Appeals Specialist II - RN

Job Summary

The Appeals Specialist II - RN reviews, analyzes, and resolves insurance denials to ensure accurate reimbursement and regulatory compliance. This role logs and reviews denials for trend reporting, provides feedback to facilities, and communicates payer updates to relevant stakeholders. The Appeals Specialist II - RN collaborates with internal teams to ensure timely and thorough appeal resolution and supports initiatives that improve denial prevention and recovery processes.

Essential Functions

• Reviews and resolves pre-payment insurance denials in collaboration with follow-up teams.
• Coordinates with Denial Coordinators, Facility Denial Liaisons, and Managed Care Coordinators to ensure payer accountability and identify education opportunities.
• Provides feedback to facilities regarding denials resulting in retractions or reimbursement impacts.
• Monitors payer billing and coding updates and communicates changes to SSC and ancillary departments.
• Tracks and logs denials and appeal activity according to established documentation and reporting guidelines.
• Prepares and distributes reports summarizing appeal trends, project updates, and payer response activity.
• Recommends process improvements to enhance appeal efficiency and reduce recurring denials.
• Maintains up-to-date knowledge of payer policies, billing and coding practices, and reimbursement regulations.
• Utilizes practice management systems and maintains documentation of appeal activity in compliance with departmental standards.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Qualifications

• H.S. Diploma or GED required
• Bachelor's Degree in Nursing preferred
• 2-4 years of experience in healthcare revenue cycle or business office required
• 1-3 years of experience in healthcare insurance or medical billing preferred

Knowledge, Skills and Abilities

• Proficiency in word processing, spreadsheet, and database applications.
• Working knowledge of billing, coding, and reimbursement principles.
• Strong analytical, research, and problem-solving skills.
• Ability to communicate effectively with payers, facility staff, and leadership.
• Strong organizational and documentation skills with attention to detail.
• Ability to work independently and manage multiple priorities in a fast-paced environment.
• Understanding of insurance claims processing and denial management workflows.

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure required

Key skills/competency

• Insurance Denials
• Regulatory Compliance
• Revenue Cycle
• Denial Prevention
• Appeal Resolution
• Medical Billing
• Coding Practices
• Reimbursement Policies
• Documentation Skills
• Payer Policies