A remote clinical appeals nurse (also known as a denials and appeals nurse) helps patients get the care they need by serving as patient advocates when claims or services are denied by insurance.
Nurses in this career review rejected medical claims. Then, they review the medical evidence to understand if the denial was appropriate. If the nurse determines that the patient truly needs the denied care, they make an appeal on the patient’s behalf.
Clinical appeals nurses play an important role in helping ensure that patients get the care they need. They often serve as a liaison between patients and insurance companies, using their clinical background to make careful assessments about what a patient needs.
Many nurses in this field love how flexible and meaningful this work can be. While there’s a steep learning curve at the beginning, the ability to work from home (without being tied to the phone all day) makes this a great career option for many people.
Learn if denials and appeals is right for you, including:
- What does a denials & appeals nurse do?
- Where do denials & appeals nurses work?
- A day in the life as a denials & appeals nurse
- Background and experience for denials & appeals nurses
- Certifications for denials & appeals nurses
- Interview tips for denials & appeals nurses
- Salary ranges for denials & appeals nurses
- Pros and cons of working as a denials & appeals nurse
What does a denials & appeals nurse do?
In utilization review and utilization management, review of services can happen at any point in the patient care journey. Prior authorization, another specialty in this field, occurs at the start of the patient journey before services are provided. The denials and appeals stage could happen if prior authorization is not approved or if insurance fails to cover services after they have been provided.
This type of nurse focuses on insurance claims that have been rejected and uses their clinical nursing judgment, structured decision-making frameworks, and information from patient records to determine whether a denied claim is justified.
If the nurse determines that the denial was not justified, the nurse then files an appeal on the patient’s behalf to advocate for insurance coverage. The nurse serves as an advocate for the patient’s needs while providing careful evidence and support for their decisions.
If the nurse determines the denial was appropriate, the nurse must also support their decision with evidence. They may also need to speak directly to patients to explain why the decision was made and what other options are available.
Other names for this career are clinical analyst, clinical appeals nurse, care coordinator, coding validation analyst, or coding educator.
|Start the day with checking any follow up denied accounts that I’ve been working on the previous day/week. Obtain denied accounts to work that are put into queues by management. Process of working an account involves insuring it’s a true denial, if so what type of denial determines the process, but in general reviewing why insurance denied services billed, medical records to determine medical necessity, other documentation by coworkers/insurance company, then after gathering information write an appeal letter to sent to insurance appealing their denial.|
Who hires denials & appeals nurses?
Denials and appeals nurses might work for:
- Hospitals and large healthcare organizations
- Clinics and private practices
- Healthcare administration companies
- Care management organizations
- Health insurance companies
Ready to learn more? You can find current openings for denials & appeals nurses on the Nurse Fern job board.
|Zero phone time, start my day at 7am ( some flexibility depending on volumes and prior permission from team leader). I can pick my break times (some days we have meetings to work around). My team doesn’t work holidays or weekends but some other teams do (I started on those teams and worked my way onto a more flexible team).|
A day in the life as a denials & appeals nurse
Denials and appeals nurses typically work five 8-hour shifts per week, but it’s possible to find part-time work or more flexible shifts. While most nurses work day shifts during the week, some appeals nurses report that they have flexible schedules that aren’t tied to typical office hours.
Some of the tasks that denials and appeals nurses perform include:
- Reviewing medical records and provider notes to understand why a treatment or service was provided
- Assessing denied claims against utilization criteria and other decision-making frameworks to understand whether it qualifies for reimbursement
- Researching healthcare regulations and care guidelines for the latest changes and updates
- Reaching out to providers or other healthcare professionals to fill in missing information or medical codes needed for reimbursement
- Filing appeals and speaking with insurance companies about denied claims throughout the appeals process
- Corresponding with patients to keep them updated on the appeals process and to understand any changes in their health status
This type of nursing requires an analytical and investigative mindset, and nurses who pursue this type of work should enjoy solving puzzles, using technology, and staying up-to-date on changes to medical billing and care guidelines.
|I do this gig PT, which I love. So when I work, I usually schedule myself for the 6a-1p shift EST. I clock in, check my emails and start in insurance claim review. I do that for the entire 7 hour shift I work, but I have opportunities to take a break and eat and use the bathroom. I am not on the phone AT ALL, which I loooove. I do use Teams Chat because that’s required to communicate, the Team Leads and the Charge Analysts direct us where to go, what claims need to be worked, and the appeals rotation. I am tied to my “office,” but I’m not in a locked room – the only place I have to put a desk is in a corner of my kitchen. My schedule is flexible in that I actually get to pick the hours and days I work. Holidays are amazing – you choose, and you only work 4 hour shifts. I am required to work a couple of weekend days in a schedule.|
Background and experience for denials & appeals nurses
While a background in case management or nursing informatics can be helpful, it’s not required. Most employers invest a lot of time in training new appeals nurses, and there are many resources available to help appeals nurses make accurate determinations.
Other beneficial experience includes:
- Familiarity with medical billing or coding
- Prior clinical experience (usually 3-5 years), particularly across different specialties
- Relevant certifications, such as CDI, case management, or utilization review/utilization management
- Experience using utilization review criteria like Interqual or the Milliman Care Guidelines
- Prior case management experience
If you don’t have specific experience with utilization review or case management, it’s still very possible to find work in this field. Other helpful skills include:
- Analytical and organizational skills
- Independent problem-solver
- Good researcher
- “Investigative” mindset
- Able to work independently and manage time well
- Dedication to helping patients
Certification options for denials & appeals nurses
There isn’t a specific certification for denials and appeals nursing, but the Association for Healthcare Denial and Appeal Management is a professional organization that offers educational webinars and other information about the career.
Additionally, certifications in areas like clinical documentation integrity, case management, or utilization review can be helpful in this field. Other helpful certifications include:
- Certified Coding Specialist (CCS) offered by The American Health Information Management Association (AHIMA)
- Certified Documentation Improvement Practitioner (CDIP), also by AHIMA
- Certified Clinical Documentation Specialist (CCDS) offered by The Association of Clinical Documentation Integrity Specialists (ACDIS)
|Once you “get” the job, it’s super easy to hit metrics. I have zero anxiety clocking in to work. I work from home, in my pjs, and do not have to talk to anyone in a daily basis.|
Interview tips for denials & appeals nurses
Nurses who are interested in denials and appeals should focus on previous experience at the bedside, in case management, or with utilization review.
Experience with electronic medical records systems and medical billing or coding is also very helpful.
It can also be helpful to consider behavioral interview questions using the STAR method. In particular, highlight experiences where you advocated for a patient or used your knowledge of the healthcare system to help a patient get the care they needed.
Before starting your job search, be sure to check out the Nurse Fern resume templates and interview preparation guides to help you put your best foot forward during the interview process. The Nurse Fern LinkedIn Course can also help you create a stellar online profile so you stand out to recruiters.
How much do denials & appeals nurses earn?
This is a highly specialized field of nursing that requires advanced knowledge and skills. It also has a direct impact on patient well-being and financial outcomes for a provider, so it is typically well compensated.
The average salary for this career is $87,245 according to ZipRecruiter. Some nurses also report that they receive bonuses for exceeding metrics.
Other benefits of this type of work include savings on commute costs, work attire, and the benefits of a more flexible work schedule.
|Yes, it is a data analytics company, and the metrics seem daunting at first, but now, less than a year later I am bonusing out every week because I am exceeding the metrics. To ensure we are hitting metrics, we are given a clicker-counter so that we can count each claim we’ve done. They are also tallied through our work site. Each is weighted differently, depending on the claim/appeal.|
Pros and cons of working as a denials & appeals nurse
Denials and appeals nursing is a popular career choice among nurses who want a remote job that doesn’t require a lot of phone time or close monitoring. This is generally a hands-off position that allows nurses to do their work independently, as long as they meet their metrics.
Many nurses also appreciate that this job is somewhat flexible, and it’s sometimes possible to shift schedules to create a good work/life balance for those with other responsibilities at home.
Many appeals nurses also report that they enjoy the work itself. This role directly impacts the care that patients receive, and working in this position allows nurses to serve as patient advocates.
Some nurses do warn that the onboarding and training for this job can feel overwhelming at first. It can also be difficult to go from bedside nursing to a job that requires sitting in front of a computer for long stretches of time. And while appeals nursing can be more flexible than other remote nursing positions, it does require set hours and metrics, which may not work for everyone.
|It can be monotonous and the metrics at first seem very overwhelming. The training time is intense and long, but it is good to see if you can make the cut. … I make a lot more money than I did as a night shift nurse, even after working 8 years on the floor. It still isn’t super great pay to some nurse standards.|
Are you interested in working as a denials & appeals nurse?
Does this type of nursing sound appealing? (Yes, we made a pun there.) If you’re interested in a high-impact career that allows you to work from home, then denials and appeals could be a good option.
Check out the Nurse Fern job board for the latest opportunities in denials & appeals nursing. Not sure if denials & appeals nursing is the right fit? Compare similar careers in data abstraction and clinical documentation integrity.