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.
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.