Clinical Denial Nurse

This is a fully remote position, open to applicants in United States.

📋 Description

• Execute pre- and post-service medical necessity evaluations for inpatient, observation, and outpatient hospital encounters.

• Utilize evidence-based guidelines such as InterQual and Milliman Care Guidelines.

• Conduct retrospective reviews of medical records to confirm documentation that supports the level of care and services provided.

• Identify root causes of denials and assess the viability of appeals.

• Prepare, submit, and monitor clinical appeals, including written submissions.

• Collaborate with teams in Patient Access, Case Management, Utilization Management, Coding, and Mid-Revenue Cycle.

• Research and apply payer-specific policies, CMS regulations, and contractual agreements.

• Track and report on denial and appeal outcomes, identify patterns, and suggest process enhancements and staff training.

• Keep accurate records of review activities in hospital and payer systems.

⛳️ Requirements

• A current unrestricted Registered Nurse license in your state of residence (Compact license preferred).

• At least five years of acute care clinical experience within a hospital environment.

• Previous experience in clinical denials, utilization review, case management, or appeals is mandatory.

• Exceptional analytical, organizational, and written communication abilities.

• Capability to independently handle multiple cases.

• Strong understanding of hospital revenue cycle processes, medical necessity reviews, and payer regulations.

• A Bachelor of Science in Nursing is required.

• Experience with inpatient level-of-care denials, DRG downgrades, and CMS payer regulations.

• Proficient in InterQual, Milliman Care Guidelines, and electronic medical record systems.

🏝️ Benefits

• Medical, Rx, Dental & Vision Insurance.

• Personal and Family Sick Time & Company Paid Holidays.

• Position may qualify for a discretionary variable incentive bonus.

• Parental Leave.

• 401(k) Retirement Plan.

• Basic Life & Supplemental Life Insurance.

• Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts.

• Short-Term & Long-Term Disability.

• Tuition Reimbursement, Personal Development & Learning Opportunities.

• Skills Development & Certifications.

• Employee Referral Program.

• Corporate Sponsored Events & Community Outreach.

• Emergency Back-Up Childcare Program.

• Flexible benefits package.

• Flexible work arrangements.