Registered Nurse (RN) Post-Claims Denial Analyst, Full Time

Hialeah Hospital • Hialeah, FL

11d

About The Position

The Post-Claims Denial Analyst RN investigates, analyzes, and resolves clinical denied medical claims to optimize reimbursement. The role uses clinical expertise and knowledge of payer policies, government regulations, and revenue cycle operations to determine the root causes of denials.

Requirements

• Active unrestricted Registered Nurse license.
• Minimum 2–5 years of clinical experience in acute care, utilization review, case management, or a similar role.
• Experience in medical claims review, appeals, or denial management within a hospital, managed care, or health system.
• Strong understanding of medical necessity, clinical guidelines, coding principles, and payer regulations.
• Knowledge of CMS guidelines, Medicare Advantage, Medicaid, and commercial payer policies.

Responsibilities

• Review denied and underpaid claims to determine the clinical and regulatory validity of denials.
• Analyze medical records and clinical documentation to support medical necessity, level of care, and correct coding.
• Submit appeal letters with supporting clinical documentation and evidence-based guidelines.
• Identify denials and recommend process improvements.
• Maintain up-to-date knowledge of Medicare, Medicaid, and commercial payer requirements.
• Track appeal outcomes and maintain detailed records to report recovery trends and financial impact.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed