Denials & Appeals Specialist (RN)

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Utilization Review Management-Fully Remote with In-Person Training Required

Monday-Friday-7:30am-4pm, Utilization Management and Denials/Appeals experience preferred.

Job Summary: The Denials & Appeals Specialist (RN) analyzes medical necessity denials, drafts detailed appeal letters, and communicates denial & appeal trends. This role communicates and works with payers in an effort to overturn medical necessity denials. Minimum Education: Has completed the basic professional curricula of a school of nursing as approved and verified by a state board of nursing, and holds or is entitled to hold a diploma or degree therefrom. Licensure, Registration and/or Certification: Valid multi-state or State of Oklahoma Registered Nurse License. Work Experience: Minimum 1 year of Utilization Review (UR) experience. Previous denials & appeals experience, preferred. Knowledge, Skills and Abilities: Superior interpersonal and communication skills, both written and verbal that present clear and concise information to a diverse audience. Demonstrated proficiency in computer applications relevant to role. Ability to multi-task in a fast-paced environment while maintaining attention to detail. Strong knowledge of utilization management, case management, and appeals processes. Working knowledge of clinical guidelines, medical necessity criteria, and payer policies. Essential Functions and Responsibilities: Reviews clinical documentation and insurance denial letters to determine the validity of denied claims and identifies appropriate appeal strategies. Assesses appropriateness of inpatient admission status bases on presenting symptoms, treatment provided, and severity of illness. Drafts appeal letters using clinical documentation and established medical necessity to advocate for appropriate reimbursement. Serves as a subject matter expert on denial management, providing insights and recommendations to leadership based on trend analysis and payer behavior. Communicates directly with payers to clarify denial reasons, request overturns, and advocate for reimbursement of medically necessary services. Applies current knowledge of healthcare laws and payer rules to guide appeal strategy and ensures compliant practices. Decision Making: Independent judgement in making decisions involving non-routine problems under general supervision. Working Relationship: Works directly with patients and/or customers. Works with internal and/or external customers via telephone or face to face interaction. Works with other healthcare professionals and staff. Special Job Dimensions: None.

Supplemental Information: This document generally describes the essential functions of the job, and the physical demands required to perform the job. This compilation of essential functions and physical demands is not all inclusive nor does it prohibit the assignment of additional duties.

Location:

EOE Protected Veterans/Disability