RN Manager, Clinical Revenue Integrity and Appeals, Full Time - Days

UChicago Medicine•Chicago, IL

13d•$124,700 - $145,400•Remote

About The Position

The Manager, Clinical Revenue Integrity & Appeals provides operational leadership and oversight of Registered Nurses supporting clinical revenue integrity and reimbursement optimization across the health system. The manager leads work with physicians, case management, utilization management, patient access, coding, revenue cycle, and payer organizations to prevent avoidable denials and maximize reimbursement through clinical review, medical necessity validation, and evidence-based appeals. The role ensures timely, accurate, and compliant review of complex payer requests, third-party audits, prior authorization denials, and post-payment clinical denials. It establishes standardized processes, monitors performance, identifies denial trends, and collaborates across clinical and revenue cycle departments to improve documentation, reduce revenue risk, and enhance financial outcomes while meeting regulatory and payer requirements. This system-level leadership position establishes consistent practices across the organization’s hospitals and ambulatory entities. The position is full-time (1.0 FTE), Monday through Friday on the day shift, in the Revenue Cycle Integrity department. The work location is flexible remote, with a commitment to work onsite when needed. The role is non-union.

Requirements

Bachelor's degree in Nursing (BSN).
Five years of progressive clinical experience in acute care, utilization management, case management, revenue cycle, clinical appeals, or related healthcare operations.
Demonstrated knowledge of medical necessity criteria, utilization review, payer authorization requirements, and clinical documentation standards.
Experience with commercial and governmental payer appeals, clinical denials, and audit management.
Current Registered Nurse (RN) license in good standing.
Strong understanding of medical necessity review, utilization management, payer reimbursement methodologies, and healthcare regulations.
Ability to interpret clinical documentation and apply evidence-based criteria to support reimbursement.
Excellent analytical, problem-solving, and critical thinking skills.
Exceptional written communication skills and experience developing persuasive clinical appeal narratives.
Ability to build collaborative relationships with physicians, nursing leadership, operational leaders, and payer representatives.
Strong project management, organizational, and process improvement capabilities.
Proficiency with electronic health records, payer portals, utilization management systems, and revenue cycle applications.
Ability to analyze data, identify trends, and translate findings into operational improvements.

Nice To Haves

Certification in Case Management (CCM), Utilization Review (CPUR or equivalent), Revenue Cycle (CRCR, CRCE), or a related professional certification.
Experience in an integrated health system or academic medical center.
Knowledge of CMS regulations, InterQual®, MCG®, and payer medical policies.

Responsibilities

Provide direct leadership, coaching, and performance management for Registered Nurses responsible for clinical revenue integrity and payer appeals.
Establish standardized workflows, productivity expectations, quality standards, and service level agreements.
Develop departmental goals, monitor key performance indicators, and implement process improvements.
Foster collaboration across Revenue Cycle, Utilization Management, Patient Access, Case Management, Coding, Clinical Documentation Integrity, Compliance, and physician leadership.
Recruit, develop, mentor, and retain a high-performing team while promoting professional development and continuous learning.
Serve as a subject matter expert on payer medical necessity requirements and clinical denial prevention strategies.
Oversee nursing review of commercial, governmental, and recovery audit requests to ensure accurate and timely clinical responses.
Ensure clinical documentation supports billed services and coordinate audit responses with appropriate stakeholders.
Identify recurring audit trends and collaborate with operational and physician leaders on corrective actions.
Oversee first-level clinical review of denials for elective services requiring prior authorization.
Ensure staff evaluate clinical documentation against payer medical policies and applicable coverage criteria.
Direct clinically sound reconsideration requests and appeals intended to obtain authorization before service whenever possible.
Collaborate with Patient Access, Financial Clearance, Scheduling, and clinical departments to reduce avoidable authorization denials and treatment delays.
Oversee comprehensive clinical appeals for post-service medical necessity denials using evidence-based guidelines, payer policies, physician documentation, and nationally recognized clinical criteria.
Ensure appeals are accurate and submitted within payer filing deadlines.
Coordinate multidisciplinary efforts to maximize reimbursement for medically necessary services.
Coordinate communication among nursing staff, physicians, advanced practice providers, and operational leaders when additional documentation is needed.
Facilitate acquisition of supplemental clinical information for peer-to-peer reviews, reconsiderations, and formal appeals.
Partner with physician advisors and utilization management leaders to improve documentation and reduce preventable denials.
Educate clinical departments about payer expectations, documentation opportunities, and denial prevention initiatives.
Ensure compliance with organizational policies, payer contracts, CMS regulations, accreditation standards, and applicable federal and state requirements.
Conduct quality reviews of clinical determinations, appeal letters, and audit responses.
Analyze denial trends, appeal success rates, audit outcomes, turnaround times, and financial recovery opportunities.
Develop action plans with operational leaders to address root causes of recurring denials.
Prepare executive reports and dashboards summarizing operational performance, financial impact, and improvement initiatives.