Clinical Denial RN
Core
Conduct pre- and post-service medical necessity reviews and retrospective medical record reviews to validate clinical documentation and resolve denials for inpatient, observation, and outpatient hospital encounters.
Role type
Senior clinical denial specialist (Registered Nurse)
Builds
Clinical appeals and denial resolution workflows for hospital revenue cycle
Domain
Healthcare administration / Medical necessity review
Required skills
Medical necessity review, InterQual criteria, Milliman Care Guidelines, retrospective record review, payer policy research, CMS regulations, denial root cause analysis, written appeals preparation, regulatory compliance
Preferred skills
Inpatient level-of-care denials, DRG downgrades, hospital revenue cycle workflows, active Compact License, master's degree in nursing
Technologies
InterQual, Milliman Care Guidelines, electronic medical record systems
Responsibilities
Conduct medical necessity reviews using evidence-based criteria; Perform retrospective medical record reviews; Identify denial root causes and determine appeal viability; Prepare and submit clinical appeals; Collaborate with Case Management and Utilization Management teams; Track and report denial trends for process improvement
Seniority
Senior, hands-on IC