Clinical Denials and Appeals RN

Job description

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 Milliman Care Guidelines. Perform 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‑Revenue 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 all review activities in hospital and payer systems in accordance with compliance standards....