Utilization Review Nurse Appeal Specialist

The UR Nurse Appeal Specialist is responsible for reviewing payer denials and authoring appeal letters, with a primary focus on Medical Necessity denials. Using strong utilization review experience and clinical judgment, the UR Nurse Appeal Specialist evaluates the medical record against payer policy, InterQual/MCG criteria, and CMS guidelines to determine whether a denial is supported by the documentation or should be appealed. The UR Nurse Appeal Specialist works under the oversight of a Physician Advisor and collaborates closely with the broader Appeal Service Line to ensure appeals are accurate, well-supported, and submitted within payer deadlines.

Responsibilities:

Medical Necessity Appeal Functions

  • Review medical necessity denials and evaluate the medical record against payer policy, InterQual/MCG criteria, and CMS guidelines to determine if an appeal is warranted
  • Author clear, well-supported medical necessity appeal letters based on clinical documentation, payer policy, and medical necessity criteria
  • Escalate complex or clinically ambiguous cases to a Physician Advisor for review and guidance
  • Collaborate with Physician Advisors on cases requiring physician-level clinical judgment or peer-to-peer support
  • Manage assigned denial review work queues to ensure timely turnaround within client or payer deadlines
  • Regulatory research as needed to support CMS requirements for medical necessity

Denials Management Functions

  • Track and trend denial reasons and outcomes to identify patterns and opportunities for improvement
  • Maintain accurate and organized documentation of all denial reviews and appeal outcomes
  • Communicate with case management, utilization management, and clinical documentation staff as needed to gather supporting information
  • Provide input and recommendations to Brundage Group leadership for process improvement and template refinement

Client & Operational Support

  • Work collaboratively with operations, client engagement, and clinical account executives to ensure cases are received and processed in a timely manner to meet payer deadlines
  • Maintain IT access to client sites
  • Maintains HIPAA compliance

Other duties as assigned.

  •  Strong utilization review/utilization management experience, including working knowledge of InterQual and/or MCG criteria
  • Strong critical thinking skills and meticulous attention to detail
  • Demonstrated ability to author clear, well-organized, and persuasive appeal letters
  • Strong understanding of medical necessity criteria and payer policy
  • Excellent written and verbal communication skills
  • Strong interpersonal skills and ability to build relationships with key team members
  • Ability to work independently and manage a caseload against payer deadlines
  • Strong computer skills and working knowledge of EMRs

Qualifications:

  • Registered Nurse (RN) with at least 3 years of acute care hospital experience
  • Minimum of 3 years of utilization review/utilization management experience
  • Prior experience authoring medical necessity appeal letters required
  • Experience with acute care hospital settings preferred

Preferred Qualifications:

  • CCM (Certified Case Manager)
  • ACM (Accredited Case Manager)
  • CHCQM certification (ABQAURP)
  • Certified Managed Care Nurse (CMCN)
  • Case Management Board Certification (CMGT-BC)
  • Experience with InterQual and/or MCG criteria certification/training

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