Denials Management Specialist (Registered Nurse (RN) License Required)
Core
Review clinical documentation and payer denials for inpatient hospital stays to determine and articulate medical necessity, writing evidence-based appeal letters for CMS and commercial claims.
Role type
Denials Management Specialist (Registered Nurse)
Builds
Appeal letters and documentation for denied inpatient claims
Domain
Healthcare / Revenue Cycle Management / Insurance Adjudication
Required skills
Clinical nursing assessment, Medical necessity determination, Appeal letter writing, Regulatory compliance, Data tracking and analysis, Root cause analysis, Process improvement, Vendor coordination
Preferred skills
Case management, Utilization management, Financial experience in appeals
Technologies
Excel, EPIC, MS Office
Responsibilities
Review inpatient retroactive denials for medical necessity, Write comprehensive appeal letters for CMS and commercial denials, Maintain accurate documentation of appeal activities, Track denial trends and outcomes, Assist Utilization Review with documentation transmission, Coordinate RAC appeals for complex cases, Implement corrective actions to minimize lost revenue
Seniority
Mid-level, hands-on IC