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 Access, 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 outcomes, identify trends, and provide 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 reside. Requires a University Degree and minimum 4-6 years of prior relevant experience in acute care clinical experience in hospital setting (Relevant experience may be substituted for formal education or advanced degree) Prior 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 Compact State RN License Experience with InterQual and/or reputed company Care Guidelines, and electronic medical record systems. 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 range for this position is $68,000.00-$113,000.00. Compensation decisions depend on a wide range 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 & Vision 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/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 reputed company Emergency Back-Up Childcare Program About reputed company reputed company is an Equal Opportunity Employer–Protected Veterans, Individuals with Disabilities or any other basis protected by law, ordinance, or regulation. reputed company will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco. If you have visited our website for information about employment opportunities, or to apply for a position, and you require an accommodation, please contact reputed company Recruiting at 1-571-633-1711 or reputed company email at RecruitingAccommodation@reputed company.com. reputed company information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation. reputed company communication regarding recruitment for a reputed company position will be sent from reputed company email domains including @reputed company.com or reputed [email protected]. Correspondence received by an applicant from any other domain should be considered unauthorized and will not be honored by reputed company. Note that reputed company will never charge a fee or require a money transfer at any stage of the recruitment process and does not collect fees from educational institutions for participation in a recruitment event. Never provide your banking information to a third party purporting to need that information to proceed in the hiring process. If any person or organization demands money reputed company to a job opportunity with reputed company, please report the matter to reputed company’s Ethics Hotline. If you want to reputed company the validity of correspondence you have received, please contact recruiting@reputed company.com. reputed company is not responsible for losses incurred (monetary or otherwise) from an applicant’s dealings with unauthorized third parties. reputed company does not accept unsolicited resumes through or from search firms or staffing agencies. reputed company unsolicited resumes will be considered the property of reputed company and reputed company will not be obligated to pay a placement fee. Apply To This Job