RN Utilization Specialist - Denials & Appeals
Southwest General•Middleburg Heights, OH
19h
About The Position
Utilization Specialist – Denials & Appeals will support the clinical staff, utilization specialists, denials management, and the Physician Advisors. This role will review patient medical records to ensure accurate documentation, proper level of care, and compliance with regulatory standards to prevent denials in the acute care setting.
Requirements
- Bachelor’s degree in nursing (BSN) preferred
- Minimum of three years of clinical nursing experience, with strong preference for experience in case management, utilization review, or CDI, in the acute care setting.
- Knowledge of ICD-10 coding guidelines, Medicare/Medicaid regulations, MCG, Cerner (EMR), MS office tools, such as Word, Excel, PowerPoint.
- Ability to analyze complex medical records and identify gaps in documentation.
- Strong verbal and written communication skills to interact with physicians and insurance payers.
- Ability to collaborate with diverse teams including nurses, physicians, and administrative staff.
- Current RN License by the Ohio State Board of Nursing.
Nice To Haves
- ACM/ACM-RN
- CCM
- CMAC
- CPHQ
