Hospital Appeals Specialist (RN), Full Time, Days,8a-4p, PFS - Revenue Cycle Integrity, Morristown, NJ

Atlantic Health System•Morristown, NJ

4d•Onsite

About The Position

The Hospital Appeals Specialist (RN) is responsible for reviewing payer denials, analyzing medical records against established criteria, and developing evidence-based appeal letters. This role involves collaborating with physician advisors, ensuring documentation accuracy, staying current with regulatory compliance, and tracking appeal outcomes to identify trends and support denial prevention initiatives. The goal is to ensure the highest quality care is delivered at the right time, place, and cost.

Requirements

Registered Nurse (RN) license.
Experience in reviewing payer denials (medical necessity, level of care, authorization, DRG downgrades).
Proficiency in analyzing medical records against criteria like MCG Guidelines and InterQual Criteria.
Experience in developing appeal letters, including for No Auth denials.
Knowledge of payer policies, CMS and NJ State regulations, and evidence-based guidelines.
Experience preparing first-level, second-level, and external appeals.
Ability to collaborate with physician advisors.
Experience in evaluating medical record completeness and accuracy.
Understanding of documentation gaps impacting reimbursement.
Familiarity with Centers for Medicare & Medicaid Services rules and commercial payer policies.
Ability to track appeal outcomes and identify denial trends.

Nice To Haves

Clinical judgment skills.
Ability to translate clinical documentation into defensible arguments.
Ability to recommend documentation improvements to providers and CDI teams.
Experience in supporting denial prevention initiatives.

Responsibilities

Review payer denials including medical necessity, level of care, authorization, and DRG downgrades.
Analyze medical records against criteria such as MCG Guidelines and InterQual Criteria.
Identify root causes of denials, such as missing documentation, authorization issues, or late UR submissions.
Write strong, evidence-based appeal letters using clinical judgment to articulate why inpatient/observation/services were appropriate.
Write appeal letters for No Auth denials, explaining the reason for failure to obtain appropriate authorization.
Reference payer policies, CMS and NJ State regulations, and evidence-based guidelines in appeal letters.
Prepare first-level, second-level, and external appeals.
Partner with physician advisors for complex or high-dollar denials.
Assist with Peer-to-Peer preparation and support.
Translate clinical documentation into defensible arguments.
Evaluate the completeness and accuracy of medical records.
Identify gaps in documentation impacting reimbursement, such as severity, risk, or intensity of service.
Recommend documentation improvements to providers and CDI teams.
Stay current with Centers for Medicare & Medicaid Services rules and commercial payer policies.
Ensure appeals meet timely filing and submission requirements.
Track appeal outcomes and overturn rates.
Identify denial trends and escalate systemic issues.
Support denial prevention initiatives with actionable insights.

Benefits

Medical, Dental, Vision, Prescription Coverage (for those working 22.5 hours per week or above).
Life & AD&D Insurance.
Short-Term and Long-Term Disability (with options to supplement).
403(b) Retirement Plan with employer match and additional non-elective contribution.
PTO & Paid Sick Leave.
Tuition Assistance, Advancement & Academic Advising.
Parental, Adoption, Surrogacy Leave.
Backup and On-Site Childcare.
Well-Being Rewards.
Employee Assistance Program (EAP).
Fertility Benefits, Healthy Pregnancy Program.
Flexible Spending & Commuter Accounts.
Pet, Home & Auto, Identity Theft and Legal Insurance.