Clinical Appeals RN Resume Sample

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Verda Rolfson
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Work Experience

Senior Clinical Appeals Rn-telecommute
03/2018 - PRESENT
New York, NY
  • Reviewing, researching and preparing 1st and 2nd level appeals functions utilizing clinical expertise
  • Verifying claim denials and accurately entering data into appropriate databases
  • Attending appeals hearings on a case to case basis
  • Determines medical appropriateness of provider services following evaluation of medical
  • Responsible for performing prior authorization review of services that require notification, using applicable benefit plan documents, evidence - based medical policy and state specific recognized clinical guidelines and criteria guidelines and benefit determination
  • Interacts with providers to obtain clinical information to support the appeals process and prior authorization determinations and provide support for their questions
  • Review provider preservice appeals for Medicare and Retirement
  • Clinical Appeals (analyzing, reviewing appeals)
  • Clinical Appeals and Grievances (analyzing, reviewing appeals / grievances)
Clinical Appeals Rn-telecommute
02/2012 - 02/2018
Houston, TX
  • Review member and provider standard and expedited pre/post-service appeals
  • Effectively and professionally communicates with both internal and external customers / providers, following prescribed policies
  • Coordinates appeals process
  • Reviews and coordinates utilization issues concurrently and retrospectively related to denials from all payer’s
  • This is a Per Diem telecommute Clinical Appeals role.
  • Constant sedentary work (desk bound or seated)
  • Constant reading is required via computer screen and/or bound printed materials
  • RN experience in an acute setting
  • A license in one of the following is required
Clinical Appeals RN
10/2006 - 09/2011
New York, NY
  • Experience in clinical nursing, PA / UM or working with individuals receiving LTSS services
  • Experience in appeals
  • Proficient level of experience with Microsoft Office Suite (Word, Outlook)
  • Experience with MCG criteria
  • Appeals and grievance experience
  • Clinical experience as an RN including in an acute, inpatient hospital setting
  • Strong computer skills including proficiency in Microsoft Office Word, Outlook, and Internet applications


University of Minnesota, Morris
2001 - 2005
Bachelor's Degree in Management

Professional Skills

  • Excellent communication, interpersonal, problem - solving and analytical skills
  • Proficient computer and typing skills (MS Word and Outlook)
  • Experience in appeals and/or prior authorization
  • Appeals, Utilization management, prior authorization or case management experience
  • Clinical experience in an acute care or an outpatient setting
  • ICD9 and CPT coding experience
  • Demonstrated ability to create, edit, save and send documents utilizing automated systems

How to write Clinical Appeals RN Resume

Clinical Appeals RN role is responsible for research, insurance, training, health, microsoft, analytical, word, typing, acute, education.
To write great resume for clinical appeals rn job, your resume must include:

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

Contact Information For Clinical Appeals RN Resume

The section contact information is important in your clinical appeals rn 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 Clinical Appeals RN Resume

The section work experience is an essential part of your clinical appeals rn 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 clinical appeals rn responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular clinical appeals rn position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions.

Representative Clinical Appeals RN resume experience can include:

  • A current, valid and unrestricted RN licensure in your state of residence
  • Utilization Review, Case Management or Medical Appeal Review experience
  • Strong Microsoft Office (Word, Excel & Outlook)
  • Utilization Review, Case Management or Medical Appeal experience
  • Previous experience in telephonic role
  • Experience in the appeals process within the healthcare industry

Education on a Clinical Appeals RN Resume

Make sure to make education a priority on your clinical appeals rn resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your clinical appeals rn 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 Clinical Appeals RN Resume

When listing skills on your clinical appeals rn 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 clinical appeals rn skills:

  • Demonstrated ability to navigate a Windows environment, including Microsoft Word and Microsoft Outlook, as well as, to conduct Internet searches
  • Clinical experience in an inpatient setting
  • Experience with electronic hospital charting systems
  • CDI or Medical Coding experience
  • RN experience in acute setting
  • Utilization Management, pre - authorization, concurrent review or appeals experience

List of Typical Skills For a Clinical Appeals RN Resume


Skills For Clinical Appeals Rn-telecommute Resume

  • Access multiple computer platforms
  • Background in Appeals and Grievances
  • Unrestricted, active RN license in state of residency
  • Active, unrestricted RN licensure in the state of residence
  • Access to high speed internet at your home
  • Current Active RN license
  • Access to a home office and high speed cable or DSL internet connection

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