Clinical Appeals Nurse

Whatever the role, everyone at Grady is part of something bigger. Choosing a career at Grady is choosing to be part of a legacy of service and commitment to our communities. If you want to make a difference, we want to hear from you.

Job Summary

The Clinical Appeals Nurse evaluates the appropriateness of payor clinical denials and level of care status downgrades by working with stakeholders throughout the health system to compose informed, effective appeals to overturn denials. This position must have strong written and verbal communication skills, leverage clinical experience at the RN level and should have a firm grasp of utilization review criteria such as InterQual. The Clinical Appeals Nurse will be responsible for appropriately tracking the status of Appeals in-process within the Epic system, report on Appeals success rates by payor and assist in identifying trends that lead to initial clinical denials.

RESPONSIBILITIES:

Composes accurate, quality clinical appeals to payors utilizing effective written communication and informed by clinical best practices.

Participates in departmental High Dollar Account discussions to assist the organization proactively billing clean claims for prompt payment.

Collaborates with stakeholders throughout the health system such as Care Management and Revenue Strategy to assist in improving processes that lead to clinical denials through trend analysis and education.

Tracks the status of appeals in-process within the Epic system; tracks, trends and reports on Appeals success rates by payor.

Ability to perform other duties as assigned

Receives requests from Accounts Receivables Representatives to review accounts for possible clinical appeals.

QUALIFICATIONS:

3 + years Audit/appeals or utilization review experience.

EDUCATION:

BS Nursing

CERTIFICATION:

Registered Professional Nurse - Georgia Secretary Of State

Core Competencies
These competencies reflect the values and behaviors expected of all Grady team members, regardless of role. They ensure that every employee contributes to safe, high-quality care, positive patient experience, and a collaborative work environment.

1. Patient-Centered Care - Demonstrates a commitment to delivering safe, compassionate, and high-quality care that prioritizes the well-being and satisfaction of patients and their families.
2.Integrity & Accountability - Acts ethically, maintains confidentiality, and accepts responsibility for actions, decisions, and outcomes.
3.Collaboration & Teamwork - Builds positive relationships, works effectively across departments, and supports colleagues to achieve shared goals.
4. Communication - Communicates clearly, respectfully, and effectively with patients, families, colleagues, and leadership.
5.Respect & Inclusion - Creates an inclusive environment by valuing diversity, treating others with dignity, and ensuring equitable care and opportunities for all.
6. Quality & Safety - Adheres to best practices, regulatory standards, and policies to ensure safe, reliable, and high-quality outcomes.
7. Adaptability & Resilience - Responds effectively to change, remains flexible in dynamic situations, and demonstrates resilience under pressure.
8. Continuous Improvement - Seeks opportunities to improve processes, skills, and outcomes through innovation, learning, and feedback.
9. Leadership & Professionalism - Inspires, guides, and develops individuals and teams while modeling professionalism, fairness, and transparency.
10. Employee Experience Focus - Champions a supportive and engaging employee journey that enables staff to thrive and, in turn, deliver exceptional patient care.

Grady Total Rewards
At Grady, we believe in supporting the health, well-being, and growth of every team member. Our Total Rewards package is designed to provide competitive pay and comprehensive benefits that make a difference in your life and career, including:

• Health & Wellness: Medical, dental, vision, and prescription drug coverage.

• Financial Security: Retirement savings plans with employer contributions, life insurance, and disability coverage.

• Work-Life Balance: Paid time off, holidays, and family leave benefits.

• Career Growth: Tuition reimbursement, professional development programs, and opportunities for advancement.

• Employee Support: Employee Assistance Program (EAP), wellness initiatives, and discounts on services.

Grady's Total Rewards are designed to ensure our employees feel valued, supported, and empowered, both at work and beyond.

Why Join Grady?
Grady Health System is more than a hospital - we are a vital part of Atlanta and the surrounding communities. For over 125 years, Grady has been committed to providing exceptional care, advancing health equity, and making a difference in the lives of those we serve. When you join Grady, you become part of a team that values excellence, compassion, innovation, and collaboration.

Here, every role matters. Whether you provide direct patient care, support our operations, or lead teams, you play an important part in fulfilling our mission. We offer opportunities to learn, grow, and build a meaningful career in an environment where your contributions are recognized and valued.

At Grady, we don't just work, we make an impact.

Equal Opportunity Employer Statement:
Grady Health System is proud to be an equal opportunity employer. We are committed to fostering a workforce where all employees feel valued, respected, and empowered to succeed. We prohibit discrimination and harassment of any kind based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other legally protected characteristic.

Grady is dedicated to creating an accessible work environment and provides reasonable accommodations to qualified individuals with disabilities to ensure equitable opportunities for success.