Clinical Appeals RN: Denials & Reimbursement Specialist

Capital Health (US); Lawrenceville (NJ); On-site; USD 92,000 - 121,000; Full time

Benefits offered by this job

Medical Plan

Dental Plan

Vision Plan

Retirement Plan

Job summary

Capital Health is seeking a Utilization Review/Denials Specialist to lead clinical appeals for denied inpatient and outpatient claims. You will apply MCG criteria and payer policies to support medical necessity and maximize reimbursement, working with physicians, CDI, UR, and non-clinical denial staff.

The role requires a registered nurse with at least three years of clinical nursing experience and knowledge of medical record documentation.

Qualifications

• Graduate of an accredited school of nursing; NJ RN license.
• Three years of clinical nursing experience required; UR, Case Management, CDI, or denial management experience.
• ACLS/NRP/PALS credentials or ability to obtain within 6 months depending on role.

Responsibilities

• Conducts comprehensive clinical review of denied inpatient and outpatient claims using MCG criteria and payer policies to determine appeal viability.
• Prepares written clinical appeals and rebuttals with medical records, MCG criteria, and payer policy language.
• Collaborates with Utilization Review, Case Management, CDI, physicians, and physician advisors to support appeal development.
• Prepares appeal packets ensuring completeness, accuracy, and deadlines.
• Maintains documentation in hospital systems related to appeal actions and rationale.

Skills

MCG criteria

Payer policies

Medical records analysis

Written communication

Verbal communication

Collaboration

Hospital information systems

Microsoft Office

Education

RN (Registered Nurse) license

Tools

Hospital information systems

Microsoft Office

Job description

Capital Health is seeking a Utilization Review/Denials Specialist to lead clinical appeals for denied inpatient and outpatient claims. You will apply MCG criteria and payer policies to support medical necessity and maximize reimbursement, working with physicians, CDI, UR, and non-clinical denial staff.

The role requires a registered nurse with at least three years of clinical nursing experience and knowledge of medical record documentation.