Denials & Appeals Specialist (RN)

Saint Francis Health System

3d • Remote

About The Position

The Denials & Appeals Specialist (RN) analyzes medical necessity denials, drafts detailed appeal letters, and communicates denial & appeal trends. This role communicates and works with payers in an effort to overturn medical necessity denials.

Requirements

• Has completed the basic professional curricula of a school of nursing as approved and verified by a state board of nursing, and holds or is entitled to hold a diploma or degree therefrom.
• Valid multi-state or State of Oklahoma Registered Nurse License.
• Minimum 1 year of Utilization Review (UR) experience.
• Superior interpersonal and communication skills, both written and verbal that present clear and concise information to a diverse audience.
• Demonstrated proficiency in computer applications relevant to role.
• Ability to multi-task in a fast-paced environment while maintaining attention to detail.
• Strong knowledge of utilization management, case management, and appeals processes.
• Working knowledge of clinical guidelines, medical necessity criteria, and payer policies.

Nice To Haves

• Previous denials & appeals experience, preferred.

Responsibilities

• Reviews clinical documentation and insurance denial letters to determine the validity of denied claims and identifies appropriate appeal strategies.
• Assesses appropriateness of inpatient admission status bases on presenting symptoms, treatment provided, and severity of illness.
• Drafts appeal letters using clinical documentation and established medical necessity to advocate for appropriate reimbursement.
• Serves as a subject matter expert on denial management, providing insights and recommendations to leadership based on trend analysis and payer behavior.
• Communicates directly with payers to clarify denial reasons, request overturns, and advocate for reimbursement of medically necessary services.
• Applies current knowledge of healthcare laws and payer rules to guide appeal strategy and ensures compliant practices.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 501-1,000 employees