Clinical Denials & Appeals Specialist - RN

About This Role

This role involves reviewing and responding to Corporate Compliance Audits, identifying denial trends and coding issues. The specialist will serve as a liaison between patients, facilities, and third-party payers to defend level of care and medical necessity.

Responsibilities

• Review and respond to Corporate Compliance Audits
• Serve as a resource for the Health System regarding denial and appeals processes
• Review denial trends and identify coding issues and knowledge gaps
• Act as a liaison between the patient, facility/physician, and third-party payer
• Prepare and defend level of care and medical necessity for assigned cases
• Collaborate with physician advisors, payor representatives, and site case managers to facilitate appropriate level of care decisions and billing status
• Ensure compliance with Utilization Review standards and regulations
• Perform concurrent and retrospective utilization management using evidence-based medical necessity criteria
• Conduct clinical reviews and formulate appeal letters to support appropriateness of admission and continued length of stay
• Ensure compliance with current state, federal, and third-party payer regulations

Requirements

• Graduate from an accredited School of Nursing
• Current License to practice as a Registered Professional Nurse in New York State

Qualifications

• Graduate from an accredited School of Nursing, Bachelor's Degree in Nursing preferred

Nice to Have

• Bachelor's Degree in Nursing
• Enrollment in an accredited BSN program within two (2) years and obtain a BSN Degree within five (5) years of job entry date
• Specialized certifications