Connecticut and New York RN Denials Specialist

Job Summary

To support the timely approval of hospital admissions and prevent payment denials, the part-time Connecticut and New York RN Denials Specialist will manage clinical reviews, communicate with payers, and ensure compliance with CMS requirements while working a hybrid schedule of 20 hours per week, primarily during evening shifts with rotating weekend and holiday coverage.

Key responsibilities

• Review inpatient admissions and observation cases within 12-24 hours, ensuring alignment with payer guidelines
• Conduct concurrent reviews for all payers, documenting and communicating relevant clinical information to secure authorizations
• Coordinate with the care team on patient status changes and escalate issues as necessary to resolve discrepancies

Required qualifications

• Current RN License in Connecticut and New York
• Minimum of 5 years of experience in acute care nursing
• Proficiency in Milliman and InterQual Guidelines
• Minimum of 2-3 years of experience as a Utilization Management Nurse in an acute care setting
• Bachelor's Degree in Nursing (BSN) is highly preferred; Associate's Degree in Nursing required with significant experience