Clinical Denials Specialist/Utilization Review RN

ERISA Recovery, Inc.; Plano (TX); On-site; USD 80,000 - 110,000; Full time

Benefits offered by this job

401(k) + company match

Paid time off

Paid lunches

Job summary

ERISA Recovery, Inc. in Plano, TX, seeks an experienced Registered Nurse (RN) to move beyond bedside care into utilization management and clinical review.

You will analyze denied claims, perform medical necessity reviews for inpatient and outpatient cases, and develop high-quality clinical appeals with peer-to-peer support. Collaborating with physicians, case managers, and UR teams, you'll resolve issues around authorizations and pre-certifications while tracking denial trends to drive process

Qualifications

• Active RN license is required.
• 3–5+ years of experience in ER Case Management or related field.

Responsibilities

• Analyze denied claims and clinical documentation to identify appeal opportunities.
• Perform medical necessity reviews for inpatient and outpatient cases.
• Develop and submit high-quality clinical appeals and support peer-to-peer reviews.
• Apply InterQual, MCG, and McKesson in case evaluations.
• Collaborate with physicians, case managers, and utilization review teams.
• Resolve issues related to authorizations, pre-certifications, and continued stay reviews.
• Track denial trends and contribute to process improvement initiatives.

Skills

RN license

Utilization management

Clinical review

Denial appeals

Medical necessity criteria

InterQual

MCG

Payer guidelines

Clinical judgment

Analytical skills

Tools

InterQual

MCG (Milliman)

McKesson

Job description

Shape Healthcare Reimbursement With Your RN Expertise

ERISA Recovery is seeking an experienced Registered Nurse (RN) with a strong background in utilization management, clinical review, and denial appeals to join our growing team in Plano.

This is an ideal opportunity for RNs to be ready to move beyond bedside care and apply their clinical judgment in a strategic, analytical role that directly impacts healthcare reimbursement.

What You’ll Do

• Analyze denied claims and clinical documentation to identify appeal opportunities
• Perform medical necessity reviews (inpatient & outpatient cases)
• Develop and submit high-quality clinical appeals and support peer-to-peer reviews
• Apply industry-standard tools: InterQual, MCG (Milliman), McKesson
• Collaborate with physicians, case managers, and utilization review teams
• Resolve issues related to authorizations, pre-certifications, and continued stay reviews
• Track denial trends and contribute to process improvement initiatives

Your Experience

• Active RN license (required)
• 3–5+ years of experience in one or more:
• ER Case Management
• Strong experience with:
• Medical necessity criteria tools (InterQual, MCG, McKesson)
• Appeals and denial overturns
• Payer guidelines and reimbursement models
• Excellent clinical judgment, writing, and analytical skills

Nice to Have

• CCM or Case Management certification
• Experience with denial analytics/reporting
• Knowledge of Medicare Advantage & Medicaid Managed Car
• Competitive salary (commensurate with experience)
• 401(k) + company match
• Paid time off
• Paid lunches
• On site only
• Must be able to commute or relocate prior to start

ERISA Recovery is a fast-growing company based in Plano, TX, specializing in the recovery of aged and complex claims using the Federal ERISA appeals process. Our collaborative and innovative team offers an extraordinary opportunity for career growth in the ever-evolving revenue cycle industry.

ERISA Recovery is an Equal Opportunity Employer