Denials Management RN — Medical Necessity & Appeals

St. Luke’s University Health Network; Allentown (Lehigh County); On-site; USD 95,000 - 120,000; Full time

Job summary

St. Luke's University Health Network seeks an experienced RN to manage denials for inpatient stays, draft evidence-based appeal letters, and ensure payer guidelines compliance.

The role involves reviewing clinical documentation, coordinating with Utilization Review, and maintaining detailed records of actions and outcomes. The candidate will leverage Excel, EPIC reporting, and MS Office tools while supporting process improvements and interdepartmental communication within the Denials Management

Qualifications

• Graduate of an accredited professional nursing program.
• Registered nurse with current license to practice in the state.
• 2-5 years of clinical nursing experience in an acute care hospital setting.
• 2-5 years’ experience in case management and/or utilization management preferred.
• Experience in appeal writing and familiarity with Excel, EPIC reporting, and MS Office.

Responsibilities

• Reviews all inpatient retroactive denials for medical necessity, late-pick-up/notification and readmission denials.
• Writes appeal letters for inpatient CMS RAC/MAC and commercial denials.
• Maintains documentation of appeal activities and logging of actions with revenue impact.
• Tracks denials and appeal outcomes to identify trends and opportunities for process improvement.
• Coordinates RAC appeals for complex case reviews and communicates with vendor for timely filing.

Skills

Case management

Utilization management

Appeal writing

Communication

Analytical thinking

Education

RN license

Nursing program graduate

Tools

Excel

EPIC reporting

MS Office

Job description

St. Luke's University Health Network seeks an experienced RN to manage denials for inpatient stays, draft evidence-based appeal letters, and ensure payer guidelines compliance.

The role involves reviewing clinical documentation, coordinating with Utilization Review, and maintaining detailed records of actions and outcomes. The candidate will leverage Excel, EPIC reporting, and MS Office tools while supporting process improvements and interdepartmental communication within the Denials Management