Clinical Appeals RN - FT - Day - Revenue Integrity & Denials Mgmt Lawrenceville NJ

Capital Health (US)•Pike, NY

1d•Onsite

About The Position

Responsible for clinical review, development, and submission of inpatient and outpatient clinical appeals for denied hospital claims. This role applies clinical expertise, medical record analysis, MCG clinical criteria, and payer-specific clinical policies to support medical necessity, patient status, and other clinical determinations in order to maximize appropriate reimbursement and reduce avoidable denials.

Requirements

Graduate of an accredited school of nursing required.
Three years' clinical nursing experience required.
Experience in utilization review, case management, clinical appeals, CDI, or denial management required.
AHA BLS - Healthcare Provider
Registered Nurse - NJ
Requires ACLS (or must obtain within 6 months of hire date) if assigned to: Critical Care/Intermediate/Telemetry, Emergency Rooms, Pediatrics/Pediatrics Emergency Room, Labor & Delivery, Surgical Services (not to include Perioperative), Interventional Procedures, Observation.
Requires NRP (or must obtain within 6 months of hire date) if assigned to: Maternity Services
Requires PALS (or must obtain within 6 months of hire date) if assigned to: Emergency Rooms, Infant Follow-Up, Surgical Services (only PACU & Same Day Surgery), Pediatrics/Pediatric ED.
Required familiarity with MCG clinical criteria for inpatient and outpatient medical necessity and patient status determinations.
Required familiarity with payer-specific clinical policies, medical necessity guidelines, and appeal requirements.
Strong understanding of inpatient and outpatient medical necessity and patient status criteria.
Ability to analyze medical records and synthesize clinical evidence into clear, persuasive written arguments.
Strong written and verbal communication skills.
Ability to work collaboratively with physicians, physician advisors, CDI, UR, and non-clinical denial staff.
Proficiency with hospital information systems and Microsoft Office applications.
Strong written and verbal communication skills.
Ability to work collaboratively with physicians, physician advisors, CDI, UR, and non-clinical denial staff.

Responsibilities

Conducts comprehensive clinical review of denied inpatient and outpatient claims using MCG criteria and payer clinical policies to determine appeal viability.
Prepares written clinical appeals and rebuttals supported by medical record documentation, MCG criteria, and payer-specific policy language.
Collaborates with Utilization Review, Case Management, CDI, physicians, and physician advisors to support appeal development.
Prepares appeal packets, ensuring completeness, accuracy, and compliance with payer submission requirements and deadlines.
Maintains clear and concise documentation in hospital systems related to appeal actions and clinical rationale.
Identifies recurring clinical denial trends related to MCG criteria application or payer policy interpretation and escalates findings to leadership.
Maintains current knowledge of MCG updates, payer policy changes, and industry best practices.
Participates in audits, education initiatives, and process improvement activities related to clinical denials and appeals.
Performs other duties as assigned and adapts to changing departmental demands.