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Job Summary: MaineGeneral Health is seeking a qualified RN Clinical Appeals Specialist to support our Revenue Cycle team by reviewing denied insurance claims and preparing clinical appeals on behalf of patients. This position plays a key role in ensuring appropriate reimbursement and compliance with payer requirements. The ideal candidate will utilize their nursing expertise to analyze clinical documentation, collaborate with providers and coding teams, and advocate for accurate claim resolution in alignment with MaineGeneral’s mission of exceptional patient care

Job Description:

Position: RN Clinical Appeals Specialist

Shift: Days, M-F

What You'll Do:

+ Conducts review of patient medical records to determine the reason for denials, utilizing clinical/regulatory standards and payer requirements. Identifies claims eligible for an appeal.

+ Prepares convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from the existing library of clinical references and/or regulatory arguments.

+ Prepares feedback and participates in meetings designed to effectively discuss and explain documentation and level of care-related decisions. Serves as a resource and liaison to staff and patients regarding denial management policies, procedures, and services.

+ Assists in utilization review, data entry, initiates outside referrals, and communicates with revenue cycle regarding denials.

What You Bring:

+ Active State of Maine RN license (or ability to obtain promptly)

+ Strong clinical knowledge, acute care experience preferred

+ Excellent written communication with attention to detail

+ Understanding of medical coding and billing

+ Familiarity with insurance and regulatory requirements

Why Join MaineGeneral:

+ Competitive Pay - Compensation that reflects your experience and the critical value of your clinical expertise.

+ Comprehensive Benefits – Health, dental, vision, and more.

+ Work-Life Balance – Generous parental leave, ample earned time off, and employee discounts.

+ Financial Security – Up to 4% retirement contributions and potential student loan reimbursement.

+ Career Growth – Opportunities to advance within our organization.

Scheduled Weekly Hours: 40

Scheduled Work Shift:

Job Exempt: No

Benefits

Supporting all aspects of our employees’ wellness – physical, emotional and financial – is a critical component of being a great place to work. With the wide range of benefits and programs available, employees have the resources they need to be well at every stage of life and plan for the future.

Physical Wellness:

+ We offer quality health, dental, and vision benefits and wellness programs and resources to provide employees access to resources for a healthy lifestyle and help manage health care costs.

+ Employees have access to industry-leading leave for new parents.

+ A generous earned time plan is offered to all employees - We believe employees need and deserve time away from work to observe holidays, be with family, go on vacation, or simply take care of themselves.

Emotional Wellness:

When life gets challenging, employees have access to our Employee Assistance Program for employees and anyone in their household.

Financial Wellness:

+ An employee discount program is available to all employees for services provided by MaineGeneral Medical Center.

+ Loan Reimbursement is available for this position dependent upon current degree level. Please discuss benefit with the recruiter.

+ Tuition Reimbursement is available to all employees to further develop skills and career.

+ We offer eligible employees up to 2% of eligible pay in 403(b) company-matching contributions plus another 2% in the 401(a) retirement income plan.

+ Three insurance plans are available to protect your family from the sudden loss of income in the event of your death, terminal illness or serious injury from accident.

+ We offer both short-term and long-term disability insurance to replace a portion of your income if you become disabled and cannot work for a period of time.

Career Mobility:Helping our employees develop their skills and grow their careers is critical to how we retain our talent and sustain our business. We do this by offering our teammates a variety of leadership-supported programs and learning and development resources for every stage of their professional development. We know that our employees are our most valuable resource they are how we grow our business and care for our community.

Equal Opportunity Employer M/F/Vet/Disability Assistive technologies are available. Application assistance for those requesting reasonable accommodation to the career site is available by contacting HR at (207) 861-3440 .

Equal Opportunity Employer M/F/Vet/Disability: In furtherance of MaineGeneral's policy regarding Equal Employment Opportunity, MaineGeneral has developed a written Affirmative Action Program which sets forth the policies, practices and procedures that MaineGeneral is committed to in order to ensure that its policy of nondiscrimination and affirmative action is accomplished.

The Affirmative Action Plan for Veterans and Individuals with Disabilities is available for inspection by any employee or candidate for employment upon request, during normal business hours, in the Human Resources Department. Assistive technologies are available. Application assistance for those requesting reasonable accommodation to the career site is available by contacting HR at (207) 861-3440 . EEO is Law (https://www.dol.gov/ofccp/regs/compliance/posters/pdf/eeopost.pdf)