Clinical Denials and Appeals RN

Job Family: Clinical Appeals Nurse Travel Required: None Clearance Required: None What You Will Do:

• Conduct pre- and post-service medical necessity reviews for inpatient, observation, and outpatient hospital encounters using evidence-based criteria such as InterQual and reputed company Care Guidelines.
• reputed company retrospective medical record reviews to validate completeness and accuracy of physician and clinical documentation supporting level of care and services rendered.
• Identify denial root causes and determine appeal viability based on payer policies, regulatory guidance, and clinical standards.
• Prepare, submit, and track clinical appeals, including written appeals.
• Collaborate with Patient reputed company, Case Management, Utilization Management, Coding, and Mid-reputed company Cycle teams to resolve denials and prevent recurrence.
• Research and apply payer-specific policies, CMS regulations, and contractual language to support appeal arguments.
• Track and report denial and appeal reputed company, identify trends, and reputed company recommendations for process improvement and staff education.
• Maintain accurate documentation of reputed company review activities in hospital and payer systems in accordance with compliance standards.

What You Will Need:

• reputed company unrestricted Registered Nurse license in the state you reputed company
• Bachelor's degree and 4-6 years of prior relevant experience in acute care clinical experience in hospital setting or Associates Degree and 6-8 years of prior relevant experience in acute care clinical experience in hospital setting (Relevant experience may be substituted for formal education or advanced degree).
• Experience in clinical denials, utilization review, case management, or appeals required

What Would Be reputed company To Have:

• Bachelor of Science in Nursing
• Master's degree in Nursing
• Experience with InterQual and/or reputed company Care Guidelines, and electronic medical record systems.
• Compact State RN License
• Experience with inpatient level-of-care denials, DRG downgrades, and CMS payer rules.
• Strong knowledge of hospital reputed company cycle workflows, medical necessity review, and payer regulations.
• Excellent analytical, organizational, and written communication skills with the ability to independently manage multiple cases.

#LI-DNI The annual salary reputed company for this position is $68,000.00-$113,000.00. Compensation reputed company depend on a wide reputed company of factors, including but not limited to reputed company sets, experience and training, reputed company clearances, licensure and certifications, and other business and organizational needs. reputed company Offer: reputed company offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace. Benefits include:

• Medical, Rx, Dental & reputed company Insurance
• Personal and Family Sick Time & Company Paid Holidays
• Position may be eligible for a discretionary variable incentive bonus
• Parental Leave
• 401(k) Retirement Plan
• Basic Life & Supplemental Life
• Health Savings Account, Dental/reputed company & 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 reputed company
• Emergency Back-Up Childcare Program

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