Clinical Appeals RN — Denials & Medical Necessity

Capital Health (US); New York (NY); On-site; USD 92,000 - 121,000; Full time

Benefits offered by this job

Medical Plan

Prescription drug coverage

Dental Plan

Vision Plan

FSA

Retirement Savings

Disability Benefits

Paid Time-Off

Commuter Transit

Commuter Parking

Job summary

Capital Health seeks a Registered Nurse to lead clinical appeals for denied hospital claims. You will apply clinical criteria and payer policies to support medical necessity and optimize reimbursement.

The role requires 3+ years of nursing experience, familiarity with MCG criteria, and strong collaboration with UR, CDI, physicians, and denial staff. 40-hour weeks and full-time status offered with competitive benefits.

Qualifications

• Graduate of an accredited school of nursing is required.
• Three years’ clinical nursing experience required; experience in utilization review, case management, clinical appeals, CDI, or denial management.
• Familiarity with MCG criteria and payer policies; strong written and verbal communication skills.
• Proficiency with hospital information systems and Microsoft Office applications.

Responsibilities

• Conducts comprehensive clinical review of denied inpatient and outpatient claims using MCG criteria and payer policies.
• Prepares written clinical appeals and rebuttals with medical records and policy language.
• Collaborates with UR, Case Management, CDI, physicians, and advisors to support appeal development.
• Prepares complete appeal packets and maintains accurate documentation in hospital systems.

Skills

Clinical nursing experience

Utilization review

Case management

CDI

Denial management

MCG criteria

Payer policies

Microsoft Office

Education

Graduate of an accredited school of nursing

Tools

Hospital information systems

Microsoft Office

Job description

Capital Health seeks a Registered Nurse to lead clinical appeals for denied hospital claims. You will apply clinical criteria and payer policies to support medical necessity and optimize reimbursement.

The role requires 3+ years of nursing experience, familiarity with MCG criteria, and strong collaboration with UR, CDI, physicians, and denial staff. 40-hour weeks and full-time status offered with competitive benefits.