Clinical Appeals RN – Denials & Revenue Integrity

Capital Health; New Jersey; On-site; USD 92,000 - 121,000; Full time

Benefits offered by this job

Medical Plan

Prescription drug coverage & In-House

Dental Plan

Vision Plan

FSA

Retirement Savings Plan

Life Insurance

Disability Benefits

Paid Time-Off

Job summary

Capital Health in Lawrenceville, NJ, is seeking a Clinical Appeals RN for a full-time day shift to review denied inpatient and outpatient claims and prepare persuasive clinical appeals using MCG criteria and payer policies. You will collaborate with Utilization Review, Case Management, CDI, physicians, and advisors to assemble appeal packets and ensure timely submission, with clear documentation.

Requirements: NJ RN license, nursing degree, 3 years clinical nursing experience; BLS required;

Qualifications

• Graduate of an accredited school of nursing.
• Three years' clinical nursing experience.
• Experience in utilization review, case management, clinical appeals, CDI, or denial management.
• AHA BLS - Healthcare Provider.
• NJ RN license; CPR.
• ACLS and/or PALS/NRP as applicable.

Responsibilities

• Conducts comprehensive clinical review of denied inpatient and outpatient claims using MCG criteria and payer clinical policies to determine appeal viability.
• Prepares written clinical appeals and rebuttals supported by medical record documentation, MCG criteria, and payer-specific policy language.
• Collaborates with Utilization Review, Case Management, CDI, physicians, and physician advisors to support appeal development.
• Prepares appeal packets, ensuring completeness, accuracy, and compliance with payer submission requirements and deadlines.
• Maintains clear and concise documentation in hospital systems related to appeal actions and clinical rationale.
• Identifies recurring clinical denial trends related to MCG criteria application or payer policy interpretation and escalates findings to leadership.
• Maintains current knowledge of MCG updates, payer policy changes, and industry best practices.
• Participates in audits, education initiatives, and process improvement activities related to clinical denials and appeals.
• Performs other duties as assigned and adapts to changing departmental demands.

Skills

MCG criteria knowledge

Payer policy familiarity

Clinical documentation analysis

Written communication

Verbal communication

Collaboration with physicians & staff

Hospital IT systems & MS Office

Education

RN license in NJ

Nursing degree

BLS for Healthcare Providers

ACLS certification (within 6 months)

NRP or PALS certification (within 6 months)

Job description

Capital Health in Lawrenceville, NJ, is seeking a Clinical Appeals RN for a full-time day shift to review denied inpatient and outpatient claims and prepare persuasive clinical appeals using MCG criteria and payer policies. You will collaborate with Utilization Review, Case Management, CDI, physicians, and advisors to assemble appeal packets and ensure timely submission, with clear documentation.

Requirements: NJ RN license, nursing degree, 3 years clinical nursing experience; BLS required;