Registered Nurse Clinical Denials

To support clinical operations, the full-time Registered Nurse Clinical Denials will conduct medical necessity reviews, manage appeals processes, and collaborate with various teams to address and prevent denials in a remote setting. Key responsibilities Conduct pre and post service medical necessity reviews using evidence-based criteria Prepare, submit, and track clinical appeals, ensuring compliance with payer policies and regulations Collaborate with cross-functional teams to resolve denials and improve processes Required qualifications Current unrestricted Registered Nurse license in the state of residence Minimum of six to eight years of relevant experience, including five years of acute care clinical experience Prior experience in clinical denials, utilization review, or case management Proficiency with InterQual, Milliman Care Guidelines, and electronic medical record systems University degree in nursing or a related field