Clinical Appeals Nurse, PRN

Netsmart

. Prepare and submit clinical appeals responding to denials from managed care organizations, governmental entities, and Recovery Audit Contractors (RACs) for hospital clients .

Posted 10/13/2026part-timeRemote • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical appeals, including preparation and submission of appeals, analysis of denial patterns, and participation in ALJ hearings. Maintains up-to-date knowledge of healthcare regulations, coding guidelines, and payer policies to effectively support appeal arguments.

Highest-signal resume keywords

Clinical Appeals ManagementCase Management ExperienceAnalytical SkillsRN LicenseMS Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AppealsUtilization ReviewMedical Record ReviewDenial AnalysisOral Argument PresentationHealthcare RegulationsCoding GuidelinesPayer PoliciesAttention to DetailProblem-Solving

Soft Skills

Written CommunicationVerbal CommunicationCollaboration

Tools & Technologies

MS Office SuiteExcelWord

Certifications & Qualifications

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

Industry Keywords

Managed Care OrganizationsRecovery Audit Contractors (RACs)Medicare PoliciesAdministrative Law Judge (ALJ) HearingsAcute Care Settings

About the role

Key responsibilities & impact

Prepare and submit clinical appeals responding to denials from managed care organizations, governmental entities, and Recovery Audit Contractors (RACs) for hospital clients
Review medical records and apply industry guidelines, Medicare policies, and best practice standards to support appeal arguments
Participate in Administrative Law Judge (ALJ) Hearings and present oral arguments supporting reversal of Medicare denials
Analyze denial patterns and contribute 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 the appeals process

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 MS Office suite, particularly Word and Excel
Strong analytical and problem-solving skills with attention to detail
All applicants must be legally authorized to work in the United States
Netsmart does not provide work visa sponsorship for this position
Successful completion of a pre-employment background check, including a drug screen
Preferred: Experience with payer-side case management or medical director-level review

Benefits

Comp & perks

Part-time employment
Remote work arrangements
Virtual collaboration tools
Occasional travel for conferences, client meetings, or in-person hearings
Pre-employment background check and drug screen provided at Netsmart’s sole expense