Appeals Nurse Resume Sample

15 votes
Antonetta Thompson
75843 White Mews,  Dallas, TX
+1 (555) 127 3306

Work Experience

Clinical Appeals Nurse
01/2017 - PRESENT
New York, NY
  • Interaction with facility Case Management, Physician Advisor is a requirement
  • RN licensure in good standing is required
  • General accounting skills and basic knowledge of third party payer is required
  • Conduct effective written and verbal communication with internal and external stakeholders including payers, patients and family members and internal department leadership is required
  • Bachelors of Nursing is required
  • Current Georgia licensure as a Registered Nurse is required
  • Receive patient history from patients, family members and physicians’ office
  • Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appellate process
  • Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual®, as evidenced by Inter-rater reliability studies and other QA audits
Grievance & Appeals Nurse
05/2010 - 11/2016
New York, NY
  • Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, etc
  • Understanding and utilization of medical necessity criteria for inpatient and outpatient services and procedures
  • Observe professional ethics in maintaining confidential information acquired concerning the personal, financial, medical or employment status of patients (and their families) provided services by the hospital
  • Manage recurring coding or clinical documentation issues and correct the underlying causes for error
  • Use discretion, knowledge and independent judgment to resolve escalated Clinical Appeals issues
  • Performs retrospective (post –discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review. 25%
  • Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appellate process. 20%
  • Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual®, as evidenced by Inter-rater reliability studies and other QA audits. 10%
Remote Appeals Nurse
05/2007 - 12/2009
Phoenix, AZ
  • Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, MedAssets (formerly IMaCs), eCARE, Authorization log, InterQual®, VI, HPF, as well as competency in Microsoft Office. 10%
  • Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, etc. 5%
  • Additional responsibilities: 5%
  • Verifying claim denials and accurately entering data into appropriate databases
  • Evaluates clinical claim denials; reviewing for appropriateness of denial or appeal based on service rendered per documentation of clinical information, interqual criteria, and other third-party information including Payer policy
  • Initiates and facilitates communications with Physician practices, UM MD, Utilization Review Nurses and Coding and case management to determine the “case for appeal”. Reviews documented clinical records and utilizes Medical necessity criteria including Interqual and Milliman to facilitate appeals for clinical denials
  • Without prompting, completes timely clinical appeals for assigned payors and follows up to ensure completion, including payment received or other resolution
  • Provides required documentation per payor request, including clinical information regarding patient's medical condition, intensity of services being utilized, treatment plan, and established review criteria, etc. to support appeal
  • Refers denied cases to Children’s attorneys for arbitration or Administrative law hearing providing all relevant medical information and documentation to aid in the process


Strayer University - Baymeadows Campus
2003 - 2007
Bachelor's Degree in Nursing

Professional Skills

  • Technical skills - Professional presentation skills needed to represent facilities in legal
  • Excellent written/verbal communication skills for interaction with various leaders and third-party payors
  • Experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background
  • Basic skills - able to perform basic mathematical calculations, balance and reconcile
  • Experience in a clinical setting with general nursing in Utilization Management
  • Experience in a supervisory role in a healthcare setting
  • Coding experience

How to write Appeals Nurse Resume

Appeals Nurse role is responsible for basic, general, mainframe, training, accounting, research, insurance, software, legal, health.
To write great resume for appeals nurse job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Appeals Nurse Resume

The section contact information is important in your appeals nurse resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

  • First and last name
  • Email
  • Telephone number

Work Experience in Your Appeals Nurse Resume

The section work experience is an essential part of your appeals nurse resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous appeals nurse responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular appeals nurse position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions. Representative Appeals Nurse resume experience can include:

  • RN or LPN experience required
  • At least one year Case Management, Utilization Management, and/or Clinical Appeals experience required
  • Current, valid RN/LPN/LVN licensure
  • Working knowledge of provider appeals process, reimbursement process, and payor requirements
  • Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements
  • Responsible for building, supporting implementation and maintaining high quality processes in order to maximize net revenue

Education on an Appeals Nurse Resume

Make sure to make education a priority on your appeals nurse resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your appeals nurse experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

  • School you graduated from
  • Major/ minor
  • Year of graduation
  • Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Appeals Nurse Resume

When listing skills on your appeals nurse resume, remember always to be honest about your level of ability. Include the Skills section after experience. Present the most important skills in your resume, there's a list of typical appeals nurse skills:

  • Clinical experience in appropriate setting
  • Previous experience with Appeals, Case Management, and Denials
  • Three-to-five years audit/appeals or utilization review experience
  • Clinical experience (medical/surgical inpatient and/or outpatient care or specialty care)
  • Experience in clinical criteria (e.g., InterQual, Milliman) that establishes medical necessity in all clinical settings
  • Experience of chart review

List of Typical Skills For an Appeals Nurse Resume


Skills For Clinical Appeals Nurse Resume

  • Communicate with physicians and professional staff, manage confidential information, and communicate findings in a professional and meaningful fashion
  • Excellent human relations and oral/written communications skills required
  • Understanding of interpersonal dynamics
  • Provides monthly Clinical denial trends to UM committee, Managed Care contracting, etc. for payor performance tracking
  • Consults with Attending Physician or Physician Advisor as appropriate in preparing appeal letters
  • Hear and differentiate low volume sounds in order to make judgments regarding actions needed
  • Leverage new and existing technology capabilities accordingly and integrate into operational processes

Skills For Grievance & Appeals Nurse Resume

  • Supports organizational efforts to ensure accurate billing and escalates cases for quality opportunity where necessary
  • Documents all action pertaining to appeals in Midas by the close of business each day
  • Conducts chart review and/or views Midas documentation criteria for submitting appeals to payors
  • Consults with Attending Physician to defend clinical necessity of a patient day
  • With director, communicates to organization opportunities for improvement in systems including documentation
  • As appeals nurse (member or provider)
  • Hear alarm bells, verbal conversations, telephone voices and normal volume sounds

Skills For PRN Appeals Nurse Resume

  • Review clinical data to determine claim payment based on company policies and
  • National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review
  • Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
  • Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions
  • Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution
  • Gather and prepare case information for Administrative Law Hearings
  • Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database

Skills For Remote Appeals Nurse Resume

  • Manage transition and business continuity of processes between the Payer Specialization Team, the SSCs and other stakeholders; engage other corporate support departments such as Education, Project Management, HR, SMEs etc. accordingly
  • Champion change management programs, with strong focus on effective and timely communication to the Payer Specialization Team, SSCs, corporate departments, payers and other stakeholders
  • Ensures up to date knowledge of payor appeal process and requirements
  • Serves as primary contact with Medicaid and third-party payors for appeals review and retrospective denials
  • Develops and/or maintains reports and information as necessary to ensure proper detail of reimbursement with regard to appeals process

Skills For Appeals Nurse Snf-remote Resume

  • Analyzes and prepares reports for presentation to financial leadership and other involved clinical specialists
  • Tracks and ensures compliance within specified timeframes and deadlines
  • Interacts personally or by telephone with both internal and external customers to share information, provide direction, or represent the department
  • Supports and participates in the continuous assessment and improvement of the quality of service provided at Children’s Healthcare of Atlanta
  • Prioritizes denials for appeal based on the following criteria: Denial reason, Payor appeal deadline, Date denial was posted, Claim dollar amount and Date of service/encounter
  • Works collaboratively with payors and other members of the healthcare team to effect timely, appropriate appeals process

Skills For RN Appeals Nurse for the WNY Health Plan-teleworker Work Resume

  • Reviews the denial reason and confirms the appropriateness of the denial code applied toward the denied claim
  • Submits appeals letters within time frames that meet payor expectations
  • Consults with Physician Advisor to resolve barriers through appropriate administrative and medical channels
  • Contacts payors when appeals are not responded to by the payor in a timely manner
  • If a denied claim is upheld or if the Appeal Nurse deems a denied claim as un-appealable, documents the outcome in Midas and notifies Patient Financial Services (PFS)
  • Documents the outcome of denials that are overturned in Midas including days and dollars that are recovered

Skills For Audit Appeals Nurse Resume

  • Provides reports and summaries in order, analyze treads by payor, physician, services etc
  • Prepares reports and summaries
  • Analyzes reports to identify systems issues
  • Monitors timelines for turnaround and submission
  • Identifies and resolves delays and obstacles to appeals
  • Tracks responses to appeals and communicates delays to supervisor

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