Clinical Nurse Specialist
About The Position
The Clinical Nurse Specialist plays a critical role in resolving complex clinical denials by translating medical documentation into clear, evidence-based appeal arguments that drive reimbursement outcomes. This role directly supports revenue recovery, reduces write-offs, and improves payer performance. By analyzing denial trends and identifying root causes, this position contributes to denial prevention strategies and continuous improvement across the revenue cycle. The Clinical Nurse Specialist also serves as a clinical resource, helping strengthen team capability and ensuring high-quality clinical review standards.
Requirements
- Strong clinical reasoning and critical thinking skills
- Ability to interpret medical documentation and payer guidelines
- Knowledge of utilization management and medical necessity criteria (e.g., InterQual, Milliman)
- Strong written communication skills for persuasive clinical appeals
- Attention to detail with ability to manage multiple priorities
- Proficiency with EMRs and healthcare systems
- Ability to work independently and collaboratively in a fast-paced environment
- Active LPN or RN license (required)
Nice To Haves
- 1+ year experience in utilization review, case management, or clinical denials
- 1+ year experience resolving hospital clinical denials
- Acute care clinical experience preferred
- Certification in Case Management or Utilization Review preferred
Responsibilities
- Review and analyze medical records and denial rationale to develop clinically supported appeal arguments
- Interpret and apply clinical guidelines (e.g., InterQual, Milliman) to support medical necessity determinations
- Prepare, edit, and enhance appeals using internal tools (e.g., DOCIQ)
- Accurately assign denial root causes and complete nurse review reporting
- Identify denial trends and escalate insights to support prevention strategies and process improvement
- Document all case activity clearly within internal and client systems
- Participate in quality control reviews and provide feedback to improve appeal effectiveness
- Serve as a clinical subject matter expert for team members and cross-functional partners
- Support onboarding, training, and ongoing education for clinical staff
- Collaborate with operations and leadership to meet client expectations and performance goals
- Maintain productivity and quality standards in a metrics-driven environment
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
