Clinical Denials & Appeals Specialist

Northeast Georgia Health System; Fruitville (FL); On-site; USD 90,000 - 120,000; Full time

Job summary

Northeast Georgia Health System (NGHS) is seeking a dedicated RN in the Denials Management team. The role supports denials, appeals, and regulatory compliance across payer types, including Federal and State programs, and engages in staff education and policy development.

The incumbent helps identify root causes and drives standard work to recover revenue while upholding clinical care standards. The position participates in governance activities, collaborates with multidisciplinary teams, and

Qualifications

• RN license in Georgia and professional certification within 2 years
• Bachelor's Degree required
• 3–5 years in case management or utilization management with acute med-surg/critical care experience
• Experience with denial management processes and payer regulations

Responsibilities

• Read and interpret the clinical care for denial assessment.
• Analyze clinical documentation to support appeals and determine validity of denials.
• Coordinate denial appeal follow-up with providers and payer input.
• Ensure actions within appeal timeframes and maintain data on denial activity.
• Serve as liaison for Patient Financial Services and contribute to education and process improvement.
• Mentor nursing staff and participate in governance related to denial management.

Skills

Analytical skills

Organizational skills

Communication skills

Negotiation skills

Independent work

Education

Bachelor's Degree

RN license in Georgia

Professional certification in clinical or education specialty

Tools

InterQual

Milliman disease management

Job description

Northeast Georgia Health System (NGHS) is seeking a dedicated RN in the Denials Management team. The role supports denials, appeals, and regulatory compliance across payer types, including Federal and State programs, and engages in staff education and policy development.

The incumbent helps identify root causes and drives standard work to recover revenue while upholding clinical care standards. The position participates in governance activities, collaborates with multidisciplinary teams, and