Registered Nurse Clinical Denials

Job Summary

To support clinical operations, the full-time Registered Nurse Clinical Denials will conduct medical necessity reviews, prepare and track clinical appeals, and collaborate with various teams to resolve denials in a remote setting.

Key responsibilities

• Conduct pre and post service medical necessity reviews using evidence-based criteria
• Prepare, submit, and track clinical appeals while collaborating with multiple departments
• Identify denial root causes and provide recommendations for process improvement

Required qualifications

• Current unrestricted Registered Nurse license in the state of residence (Compact license preferred)
• Minimum of five years of acute care clinical experience in a hospital setting
• Prior experience in clinical denials, utilization review, case management, or appeals
• Bachelor of Science in Nursing required
• Proficiency with InterQual and Milliman Care Guidelines