Job Description
Job Description
Appeals Specialist (LPN, RN, or Therapist)
Location: Massachusetts (RegalCare Facility network / Hybrid-Remote options available)
Position Type: Full-Time
Role Overview
RegalCare is seeking a detail-driven Appeals Specialist to lead our clinical appeals, audit management, and medical records oversight. In this vital role, you will review clinical denials, construct compelling clinical arguments, and interface with payers to protect reimbursement and ensure documentation compliance across our Massachusetts facilities.
Key Responsibilities
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Appeals Management: Analyze insurance denials, Medicare/Medicaid rejections, and managed care disputes. Gather clinical evidence and draft comprehensive appeals to overturn adverse determinations.
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Audit Oversight: Coordinate internal and external clinical audits, ensuring timely responses, accurate data compilation, and adherence to regulatory standards.
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Medical Records Integrity: Partner with facility Director of Nursing, MDS Coordinators, and therapy teams to audit medical records for completeness, clinical necessity, and coding accuracy.
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Clinical Collaboration: Work directly with multidisciplinary care teams (LPNs, RNs, PT/OT/ST Therapists) to educate staff on proper documentation habits that prevent future denials.
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Tracking & Reporting: Maintain a centralized tracking system for all pending appeals, audit outcomes, and financial recovery metrics, presenting regular updates to leadership.
Qualifications & Requirements
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Licensure: Active, unencumbered Massachusetts license as a Registered Nurse (RN), Licensed Practical Nurse (LPN), or Physical/Occupational/Speech Therapist.
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Experience: Minimum 2–3 years of clinical experience in skilled nursing, long-term care, or healthcare administration.
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Expertise: Demonstrated working knowledge of Medicare Part A/B, Medicaid, Managed Care guidelines, and clinical reimbursement rules.
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Skills: Exceptional written and verbal communication skills, strong analytical capability, and proficiency in electronic health record (EHR) systems.