Registered Nurse Clinical Denials Specialist

Job Summary

Seeking a skilled Clinical Denials and Appeals Specialist, this remote full-time position will focus on reviewing complex payer denials and developing high-quality appeal letters to maximize reimbursement recovery for healthcare clients.

Key Responsibilities

• Generate comprehensive appeal letters for denied claims and track their status and outcomes
• Conduct detailed analyses of denials related to medical necessity, level of care, and authorization issues
• Apply CMS regulations and maintain knowledge of coding requirements to support appeal arguments

Required Qualifications

• Active Registered Nurse (RN) license required; BSN preferred
• Minimum 5 years of clinical nursing experience
• Minimum 3-5 years of experience in denials management and appeals generation
• Strong knowledge of medical necessity criteria, DRG reimbursement methodology, and Medicare/Medicaid regulations
• Experience using InterQual and/or MCG criteria