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Clinical Denials & Appeals Specialist (RN) - Remote ID-21303

About the position

The Clinical Denials & Appeals Specialist (RN) plays a crucial role in reviewing and responding to corporate compliance audits, serving as a resource for the health system. This position focuses on analyzing denial trends, identifying coding issues, and bridging communication between patients, facilities, and third-party payers to ensure appropriate care and compliance with regulations.

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Responsibilities

  • Serve as a liaison between the patient, facility/physician, and third-party payer.
  • Prepare and defend the level of care and medical necessity for assigned cases.
  • Collaborate with physician advisors, payor representatives, and site case managers to facilitate appropriate level of care decisions and billing status.
  • Perform concurrent and retrospective utilization management using evidence-based medical necessity criteria.
  • Conduct clinical reviews and formulate appeal letters to support the appropriateness of admission and continued length of stay.
  • Ensure compliance with current state, federal, and third-party payer regulations.
  • Maintain up-to-date clinical reviews and appeals that accurately reflect the patient's severity of illness and intensity of services provided.
  • Perform Patient Review Instruments (PRI's) as needed.

Requirements

  • Graduate from an accredited School of Nursing.
  • Current License to practice as a Registered Professional Nurse in New York State required.
  • Must be enrolled in an accredited BSN program within two (2) years and obtain a BSN Degree within five (5) years of job entry date.

Nice-to-haves

  • Prior experience in Case Management, Appeals & Denials, and/or Utilization Review, highly preferred.

Benefits

  • Competitive salary based on experience and qualifications.
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