Registered Nurse Clinical Denials

Job Summary

To support clinical operations, the full-time Registered Nurse Clinical Denials will conduct medical necessity reviews, manage appeals processes, and collaborate with various teams to address and prevent 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, ensuring compliance with payer policies and regulations
• Collaborate with cross-functional teams to resolve denials and improve processes

Required qualifications

• Current unrestricted Registered Nurse license in the state of residence
• Minimum of six to eight years of relevant experience, including five years of acute care clinical experience
• Prior experience in clinical denials, utilization review, or case management
• Proficiency with InterQual, Milliman Care Guidelines, and electronic medical record systems
• University degree in nursing or a related field