Clinical Appeals/Denials RN
About The Position
This role involves conducting pre- and post-service medical necessity reviews for various hospital encounters, performing retrospective medical record reviews to ensure documentation accuracy, and identifying denial root causes to determine appeal viability. The Clinical Appeals/Denials RN will prepare, submit, and track clinical appeals, collaborate with internal teams to resolve denials, and research payer policies and regulations to support appeal arguments. Additionally, the role includes tracking and reporting denial and appeal outcomes, identifying trends, and maintaining accurate documentation of all review activities.
Requirements
- Current unrestricted Registered Nurse license in the state you reside.
- Requires a University Degree and minimum 4-6 years of prior relevant experience in acute care clinical experience in hospital setting (Relevant experience may be substituted for formal education or advanced degree)
- Prior experience in clinical denials, utilization review, case management, or appeals required.
Nice To Haves
- Bachelor of Science in Nursing
- Master’s degree in Nursing
- Experience with InterQual and/or Milliman Care Guidelines, and electronic medical record systems.
- Compact State RN License
- Experience with inpatient level-of-care denials, DRG downgrades, and CMS payer rules.
- Strong knowledge of hospital revenue cycle workflows, medical necessity review, and payer regulations.
- Excellent analytical, organizational, and written communication skills with the ability to independently manage multiple cases.
Responsibilities
- Conduct pre- and post-service medical necessity reviews for inpatient, observation, and outpatient hospital encounters using evidence-based criteria such as InterQual and Milliman Care Guidelines.
- Perform retrospective medical record reviews to validate completeness and accuracy of physician and clinical documentation supporting level of care and services rendered.
- Identify denial root causes and determine appeal viability based on payer policies, regulatory guidance, and clinical standards.
- Prepare, submit, and track clinical appeals, including written appeals.
- Collaborate with Patient Access, Case Management, Utilization Management, Coding, and Mid-Revenue Cycle teams to resolve denials and prevent recurrence.
- Research and apply payer-specific policies, CMS regulations, and contractual language to support appeal arguments.
- Track and report denial and appeal outcomes, identify trends, and provide recommendations for process improvement and staff education.
- Maintain accurate documentation of all review activities in hospital and payer systems in accordance with compliance standards.
Benefits
- Medical, Rx, Dental & Vision Insurance
- Personal and Family Sick Time & Company Paid Holidays
- Parental Leave
- 401(k) Retirement Plan
- Basic Life & Supplemental Life
- Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
- Short-Term & Long-Term Disability
- Tuition Reimbursement, Personal Development & Learning Opportunities
- Skills Development & Certifications
- Employee Referral Program
- Corporate Sponsored Events & Community Outreach
- Emergency Back-Up Childcare Program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
