Clinical Appeals Nurse Career
When a patient’s insurance rejects a claim or denies coverage for medical treatment or a specific procedure, a clinical appeals nurse handles all aspects of an appeal. They assess the patient’s situation, including every detail related to the insurance claim, its denial, and the treatment to be received, before deciding whether or not to move forward with the appeals process.
Individuals with a passion for nursing and a desire to help ensure all patients receive the right level of care can find a rewarding career as a clinical appeals nurse. As a direct representative of their hospital, nursing clinic, or medical center, the role of a clinical appeals nurse offers a rewarding career and a potential stay-at-home nursing job opportunity. If you thrive in a healthcare environment and enjoy employee and business management, you could fit well into the career of a clinical manager.
Serving as the defense for a patient with a rejected claim, a clinical appeals nurse must provide sufficient medical evidence to support any appeal. As one of the more exciting nursing careers available today, clinical appeals nurses are immediately responsible for helping patients achieve the care they need.
If they determine that a patient needs treatment which an insurance carrier has denied, they fulfill all aspects of the appeals process on that patient’s behalf. When pre-existing conditions, current medical regulations, or a patient’s general health means they are not a good candidate to receive the rejected treatment, a clinical appeals nurse must explain as much to the patient.
On a daily basis, the role of a clinical appeals nurse can change according to individual patient needs. Their exact responsibilities can often include:
- Correspondence with insurance providers—to appeal insurance decisions contrary to the best interests of the patient.
- Correspondence with patients—to identify whether their current symptoms warrant further care.
- Correspondence with patients’ families—to keep all loved ones informed on a patient’s health and on the status of the appeals process.
- Report creation and submission of an appeal—complete with all necessary details to inform insurance carriers of a patient’s continued needs.
- Research into current healthcare regulations and stipulations—to form the basis for any necessary appeal.
- Investigation into a patient’s history treatment—to better warrant their need for continual care.
- Reviewing response letters from insurance carriers—and following up whenever necessary.
These responsibilities mean that clinical appeals nurses must be well informed on all healthcare regulations while they remain in contact with all patients requiring care.
In most cases, the location where a clinical appeals nurse works is determined by their employer. Many clinical appeals nurses work directly on-site at their hospital or health clinic, given the value of direct proximity and communication with patients requiring help in their insurance appeals process.
However, the nature of the role also means that clinical appeals nurses can also work virtually. As long as clinical appeals nurses have a way to maintain communication with clients, they can leverage their understanding of medical codes to complete an appeals process while working from home.
As a highly specialized career choice, the position of a clinical appeals nurse requires extensive education. Students must first obtain a degree in nursing or complete a nursing prelicensure program in their state to become a registered nurse (RN). This will allow you to obtain a nursing license, together with the necessary understanding of medical codes and regulations for use in your career.
After completing your degree and licensure, students looking to become clinical appeals nurses will also likely need to gain experience in either a medical coding or clinical field. In particular, pursuing a Master of Science in Nursing–Leadership and Management could help equip aspiring appeals nurses with a deeper knowledge of clinical health quality principles, the needs and limitations of all stakeholders (including clinics, governments, corporations, and patients) along with other practical skills and professional knowledge. Gaining a deeper understanding of administrative and systemic issues in healthcare can equip nurses to be better advocates and representatives for patients and providers in situations that require some form of appeal.
Nursing (Prelicensure) – B.S.
A one-of-a-kind nursing program that prepares you to be an RN...
A one-of-a-kind nursing program that prepares you...
A one-of-a-kind nursing program that prepares you to be an RN and a baccalaureate-prepared nurse:
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- Tuition and fees: $6,575 per 6-month term.
WGU offers the prelicensure program in areas where we have partnerships with healthcare employers to provide practice sites and clinical coaches to help teach you and inspire you on your path to becoming a nurse.
If you don't live in one of our prelicensure states or don't qualify to apply, consider getting our Bachelor's Degree in Health Services Coordination instead. This degree allows you to work inside the healthcare industry, while also working directly with patients who need help.
Nursing (RN-to-BSN Online) – B.S.
An online BSN degree program for registered nurses (RNs) seeking...
An online BSN degree program for registered...
An online BSN degree program for registered nurses (RNs) seeking the added theoretical depth, employability, and respect that a bachelor's degree brings:
- Time: 66% of graduates finish within 18 months.
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- Transfers: On average, students transfer 81 credits.
With over 35,000 BSN alumni, this is one of WGU's most popular online degree programs. View our RN to BSN degree guide.
If you don't currently have an RN and don't qualify for your nursing prelicensure program, consider getting our Bachelor's Degree in Health Services Coordination instead. This degree allows you to work inside the healthcare industry in a unique way.
Nursing – Leadership and Management (BSN-to-MSN) – M.S.
For registered nurses with a bachelor's degree who are ready for...
For registered nurses with a bachelor's degree...
For registered nurses with a bachelor's degree who are ready for greater responsibility:
- Time: 82% of grads finish within 24 months.
- Tuition and fees: $4,385 per 6-month term, plus a Health Professions Student Fee of $350.
Sample careers and jobs this degree program will prepare you for:
- Director of Nursing
- Chief Nursing Officer
- Quality Director
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- Project Manager
The Bureau of Labor Statistics projects employment of medical and health services managers to grow 17% by 2024, much faster than the average for all occupations.
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A clinical appeals nurse regularly uses specific skills while on the job to help connect patients with the care they need. These individual skills can include:
- Interpersonal communication: the ability to expertly communicate with insurance providers, patients, and patient families regarding continued care and the status of any appeals process.
- Expedited research: the ability to quickly comb through healthcare regulations to find litigation that will strengthen an appeals claim.
- Healthcare reporting: the ability to draft reports documenting the progress of any appeals process through the completion of the appeal.
- Problem solving: the ability to understand a patient’s issues and take steps to remedy them.
- Teamwork: the ability to work in tandem with healthcare staffing, nurses, doctors, and insurance personnel to ensure that patients receive appropriate levels of care.
A clinical appeals nurse maintains a strong sense of responsibility for all patients. He or she will work continuously to connect them with the treatment they need to achieve an improved quality of life, especially if an insurance provider is at first unwilling to do so.
How Much Do Clinical Appeals Nurses Make?
The exact income of a clinical appeals nurse can vary, depending on factors that include their years of experience, employer, employer location, and nursing tier. In general, the salary of a clinical appeals nurse can average $84,117, often ranging between $58,704 and $104,571.
What Is the Projected Job Growth?
Employment for individuals in the nursing profession is expected to grow 7% from 2019 to 2029, a forecasted industry expansion faster than the average across all markets.
This expected growth is due in large part to the expanding need for healthcare services in general as populations continue to age. This will mean an increased demand for nursing staff to provide care for chronic issues and a parallel need for clinical appeals nurses to address rejected insurance claims.
Do Clinical Appeals Nurses Need Certification?
All clinical appeals nurses must be fully licensed, which means passing the NCLEX exam. This can mean either passing the NCLEX-RN exam to become a registered nurse, or completing the NCLEX-PN to become a licensed practical nurse (LPN).
To sign up for the NCLEX exam, students must first obtain authorization to test (ATT) from the nursing regulatory body (NRB). This authorization clears students to then register for the exam itself. Because this procedure can take time, students should begin the application process well before their intended testing date.