Clinical Denials & Appeals Specialist (RN) - Remote

Northwell Health • Melville, NY

393d • Remote

About The Position

The Clinical Denials & Appeals Specialist (RN) plays a crucial role in reviewing and responding to corporate compliance audits, serving as a resource for the health system. This position focuses on analyzing denial trends, identifying coding issues, and bridging communication between patients, facilities, and third-party payers to ensure appropriate care and compliance with regulations.

Requirements

• Graduate from an accredited School of Nursing.
• Current License to practice as a Registered Professional Nurse in New York State required.
• Must be enrolled in an accredited BSN program within two (2) years and obtain a BSN Degree within five (5) years of job entry date.

Nice To Haves

• Prior experience in Case Management, Appeals & Denials, and/or Utilization Review, highly preferred.

Responsibilities

• Serve as a liaison between the patient, facility/physician, and third-party payer.
• Prepare and defend the level of care and medical necessity for assigned cases.
• Collaborate with physician advisors, payor representatives, and site case managers to facilitate appropriate level of care decisions and billing status.
• Perform concurrent and retrospective utilization management using evidence-based medical necessity criteria.
• Conduct clinical reviews and formulate appeal letters to support the appropriateness of admission and continued length of stay.
• Ensure compliance with current state, federal, and third-party payer regulations.
• Maintain up-to-date clinical reviews and appeals that accurately reflect the patient's severity of illness and intensity of services provided.
• Perform Patient Review Instruments (PRI's) as needed.

Benefits

• Competitive salary based on experience and qualifications.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree