Clinical Denials and Appeals RN

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

📋 Description

• Execute pre‑ and post‑service medical necessity assessments for inpatient, observation, and outpatient hospital visits utilizing evidence‑based criteria such as InterQual and Milliman Care Guidelines.

• Conduct retrospective medical record assessments to ensure the completeness and accuracy of physician and clinical documentation that supports the level of care and services provided.

• Determine the root causes of denials and assess the viability of appeals based on payer policies, regulatory guidance, and clinical standards.

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

• Work in partnership with Patient Access, Case Management, Utilization Management, Coding, and Mid‑Revenue Cycle teams to address denials and prevent future occurrences.

• Investigate and apply payer-specific policies, CMS regulations, and contractual language to bolster appeal arguments.

• Monitor and report denial and appeal results, identify patterns, and offer suggestions for process enhancements and staff training.

• Ensure accurate documentation of all review processes in hospital and payer systems in compliance with regulatory standards.

⛳️ Requirements

• Must possess a current unrestricted Registered Nurse license in your residing state.

• A University Degree and a minimum of 4-6 years of relevant acute care clinical experience in a hospital environment are required.

• Relevant experience may be considered in lieu of formal education or advanced degrees.

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

• A Bachelor of Science in Nursing is preferred.

• A Master’s degree in nursing is preferred.

• A Compact State RN License is preferred.

• Familiarity with InterQual and/or Milliman Care Guidelines, along with electronic medical record systems, is preferred.

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

• Exceptional analytical, organizational, and written communication skills with the capacity to independently handle multiple cases.

🏝️ Benefits

• Medical, Rx, Dental & Vision Insurance

• Personal and Family Sick Time & Company Paid Holidays

• Parental Leave

• 401(k) Retirement Plan

• Basic Life & Supplemental Life

• 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