OVERVIEW
What is a Clinical Appeals Nurse?
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.
RESPONSIBILITIES
What Does a Clinical Appeals Nurse Do?
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.
EDUCATION & BEST DEGREES
How Do I Become a Clinical Appeals Nurse?
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 or Post-Master's certificate in Nursing - Leadership & 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.
Best Degrees for a Clinical Appeals Nurse
Health & Nursing
Nursing (Prelicensure) – B.S.
A one-of-a-kind nursing program that prepares you to be an RN and a...
A one-of-a-kind nursing program that prepares you to be an RN and a baccalaureate-prepared nurse:
- Locations: Due to in-person clinical requirements, students must be full time residents of FL, ID, IN, IA, KS, KY, NV, NM, NC, OH, OK, SC, TN, TX, UT to enroll in this program. The coursework in this program is offered online, but there are in-person requirements.
- Tuition: $6,430 per 6-month term for the first 4 terms of pre-nursing coursework and $8,755 per 6-month term for the remaining 4 terms of clinical nursing coursework.
- Time: This program has a set pace and an expected completion time of 4 years. Certain coursework may be accelerated to finish faster.
- 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 in Health and Human Services instead. This degree allows you to work inside the healthcare industry, while also working directly with patients who need help.
Skills for your résumé that you will learn in this program:
- Community Health
- Women's and Children's Nursing
- Pathology
- Physiology
- Research
Health & Nursing
Nursing (RN-to-BSN Online) – B.S.
An online BSN degree program for registered nurses (RNs) seeking the added...
An online BSN degree program for registered nurses (RNs) seeking the added theoretical depth, employability, and respect that a bachelor's degree brings:
- Time: 61% of graduates finish within 20 months.
- Tuition: $4,685 per 6-month term.
- Courses: 23 total courses in this program.
- Transfers: Students can transfer up to 90 credits.
Skills for your résumé that you will learn in this program:
- Healthcare Policy and Economics
- Information Technology in Nursing Practice
- Anatomy and Physiology
- Applied Healthcare Statistics
If you don't currently have an RN and don't qualify for your nursing prelicensure program, consider getting our Bachelor's in Health and Human Services instead. This degree allows you to work inside the healthcare industry in a unique way.
Health & Nursing
Nursing – Leadership & Management (RN-to-MSN) – M.S.
This program for RNs includes a BSN component and is a substantial leap...
This program for RNs includes a BSN component and is a substantial leap toward becoming a nurse leader.
- Time: 62% of RN-to-MSN grads finish within 37 months.
- Tuition: $4,685 per 6-month term during undergraduate portion and $4,795 per 6-month term during graduate portion.
- Courses: 32 total courses in this program.
Skills for your résumé you will learn in this program:
- Quality Outcomes in a Culture of Value-Based Nursing Care
- Nursing Leadership and Management
- Advanced Pathopharmacological Foundations
- Informatics for Transforming Nursing Care
If you're driven to lead, this online nursing degree will provide you everything needed to make that career a reality. This program is ideal for current RNs who are interested in earning both their BSn and MSN in an accelerated program.
Compare degrees
This program is not the only degree WGU offers designed to create leaders in the field of healthcare. Compare our health leadership degrees.
Health & Nursing
Nursing – Leadership & 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 who are ready for additional career opportunities.
- Time: 61% of grads finish within 23 months
- Tuition: $4,795 per 6-month term
- Courses: 15 total courses in this program
This program is ideal for current RNs who have a BSN and are ready for the next step in their education.
Skills for your résumé you will learn in this program:
- Quality Outcomes in a Culture of Value-Based Nursing Care
- Nursing Leadership and Management
- Advanced Pathopharmacological Foundations
- Informatics for Transforming Nursing Care
Compare degrees
This program is not the only degree WGU offers designed to create leaders in the field of healthcare. Compare our health leadership degrees.
Health & Nursing
Nursing Leadership and Management – Post-Master's Certificate
A certificate for registered nurses with a master's degree in nursing who...
A certificate for registered nurses with a master's degree in nursing who are ready for greater responsibility in a leadership and management role.
- Time: Students typically finish this program in 12 months.
- Tuition: $4,795 per 6-month term. The cost to sit for the NAHQ Certified Professional in Healthcare Quality (CPHQ) exam is included in tuition.
- Courses: 8 total courses in this program.
Skills for your résumé that you will learn in this program:
- Strategic Planning
- Resource Management
- Business Case Analysis
- Evaluating Healthcare Improvements
Health & Nursing
Health and Human Services – B.S.
An online health degree program for students who are committed to making a...
An online health degree program for students who are committed to making a difference for patients in a variety of ways.
- Time: 63% of students finish this program in 24 months
- Tuition: $4,085 per 6-month term
- Courses: 35 total courses in this program
Skills for your résumé that you will learn in this program:
- Epidemiology
- Community and Public Health
- Cultural Awareness
- Pathophysiology
- Healthcare Values and Ethics
- Substance Abuse Support
This degree allows you to work inside the healthcare industry, while also directly working with patients who need help.
How Much Does a Clinical Appeals Nurse Make?
$90,777
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 $90,777.
What Is the Projected Job Growth?
6%
While specific data for a clinical appeals nurse is absent from the Bureau of Labour Statistics (BLS), the statistics for registered nurses are very healthy. The BLS anticipates a 6% growth between the 2022 to 2032 period alone.
SKILLS
What Skills Does a Clinical Appeals Nurse Need?
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.
- Problem solving: the ability to understand a patient’s issues and take steps to remedy them.
- Healthcare reporting: the ability to draft reports documenting the progress of any appeals process through the completion of the appeal.
- 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.
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