Clinical Denials & Appeals Nurse Leader

Care New England; Providence (RI); On-site; USD 95,000 - 125,000; Full time

Job summary

Care New England is seeking a Clinical Denial Supervisor to lead advanced denial management for hospital care. This role analyzes clinical documentation, builds compelling payer appeals, and ensures timely submission while aligning with payer policies.

The position requires nursing licensure, CCM/ACM certification, and hospital case management experience with denials. The supervisor will educate staff and collaborate with care management leadership to reduce write-offs.

Qualifications

• Bachelor’s degree in nursing is required.
• Two years of hospital case management experience with denials review.
• Certification in Care Management (CCM/ACM) required; within two years of hire if not already held.

Responsibilities

• Research clinical denials related to referral and medical necessity; initiate appeals.
• Submit detailed appeals to payers per Medicare/Medicaid guidelines and CNE policies.
• Initiate peer-to-peer reviews with payers and relevant bodies to resolve denials.
• Monitor and follow up on appeals through the process.
• Maintain accurate and timely documentation of denied cases.
• Develop and evaluate processes to ensure timely collection of information.
• Serve as a resource for concurrent denials for hospital case management.
• Educate staff, physicians, and payers on reimbursement issues and care protocols.
• Coordinate status determinations using InterQual and Medicare guidelines.
• Identify denial patterns and escalate with sufficient information for root-cause resolution.
• Tabulate financial gains and improvement opportunities.
• Review payer communications for risk to reimbursement and escalate as needed.
• Submit retro-authorizations in line with payer requirements.

Skills

InterQual knowledge

Medicare guidelines

Denial management

Audit/compliance

Education

Bachelor’s degree in nursing

CCM or ACM certification

RI State Nursing Licensure

Tools

EMR system

InterQual reference materials

Job description

Care New England is seeking a Clinical Denial Supervisor to lead advanced denial management for hospital care. This role analyzes clinical documentation, builds compelling payer appeals, and ensures timely submission while aligning with payer policies.

The position requires nursing licensure, CCM/ACM certification, and hospital case management experience with denials. The supervisor will educate staff and collaborate with care management leadership to reduce write-offs.