Clinical Nurse Appeal Analyst

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At Exact Sciences, we're helpingchange how the world prevents, detects and guides treatment for cancer. We give patients and clinicians the clarity needed to make confident decisions when they matter most. Join our team to find a purpose-driven career, an inclusive culture, and robust benefits to support your life while you're working to help others.

Position Overview

The Clinical Nurse Appeal Analyst is responsible for reviewing, analyzing, and responding to clinical denials from payers. This role serves as a critical liaison between clinical departments and the Revenue Cycle Team, ensuring that appeals are supported by appropriate clinical documentation and medical necessity. The ideal candidate will have a strong clinical background, excellent analytical skills, a deep understanding of payer policies, and utilization of review criteria as well as creating strong appeal letters.

Essential Duties

Include, but are not limited to, the following:

• Review payer denials related to medical necessity, level of care, and clinical documentation.
• Analyze patient medical records to determine the appropriateness of care and services provided.
• Draft and submit timely, evidence-based clinical appeals to payers.
• Collaborate with physicians, case management, and coding teams to gather supporting documentation when needed.
• Monitor appeal outcomes and identify trends in denials to inform process improvements.
• Maintain up-to-date knowledge of payer guidelines, CMS regulations, and industry best practices.
• Educate revenue cycle and non-clinical staff on denial trends and documentation of improvement opportunities.
• Educate and support non-clinical staff on how to interpret medical policies and draft compelling arguments to overturn denials.
• Support clinical appeal strategy.
• Participate in denial management meetings and performance improvement initiatives.
• Strong clinical judgment and critical thinking.
• Excellent written and verbal communication skills.
• Proficiency in EMR systems and denial management tools.
• Ability to work independently and manage multiple priorities.
• Uphold company mission and values through accountability, innovation, integrity, quality, and teamwork.
• Support and comply with the company's Quality Management System policies and procedures.
• Maintain regular and reliable attendance.
• Ability to act with an inclusion mindset and model these behaviors for the organization.
• Ability to work designated schedule.
• Ability to work overtime, as needed.
• Ability to work on a mobile device, tablet, or in front of a computer screen and/or perform typing for approximately 100% of a typical working day.
• Ability to work on a computer and phone simultaneously.
• Ability to use a telephone through a headset.
• Ability to work seated for approximately 100% of a typical working day
• You will be required to successfully complete an assessment showing understanding of Exact Sciences Epic processes necessary to the job functions with a score of 80% or higher. Exact Sciences will make a reasonable accommodation available, if necessary, to assist an employee with a disability to satisfy this requirement.

Minimum Qualifications

• Associates Degree in Nursing.
• 3+ years of experience in clinical appeals, utilization review, or case management.
• Ability to work independently and manage multiple priorities.
• Familiarity with payer guidelines and medical necessity standards.
• Possession of active RN license at time of hire and maintain throughout employment in position.
• Demonstrated ability to perform the essential duties of the position with or without accommodation.
• Applicants must be currently authorized to work in country where work will be performed on a full or part-time basis. We are unable to sponsor or take over sponsorship of employment visas at this time.

Preferred Qualifications

• Strong clinical judgment and critical thinking.
• Excellent written and verbal communication skills.
• Proficiency in EMR systems and denial management tools.
• Advanced computer skills to include internet navigation and email usage.
• Strong in Microsoft Office programs, such as: Word, Excel, Outlook, OneNote, and SharePoint.

Salary Range:

Exact Sciences is proud to offer an employee experience that includes paid time off (including days for vacation, holidays, volunteering, and personal time), paid leave for parents and caregivers, a retirement savings plan, wellness support, and health benefits including medical, prescription drug, dental, and vision coverage. Learn more about our benefits.

Our success relies on the experiences and perspectives of a diverse team, and Exact Sciences fosters a culture where all employees can develop personally and professionally with a sense of respect and belonging. If you require an accommodation, please contact us here.

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We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to disability, protected veteran status, and any other status protected by applicable local, state, or federal law.

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