Denials Management Specialist (Registered Nurse (RN) License Required)

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 is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

JOB DUTIES AND RESPONSIBILITIES

Reviews all Inpatient Retroactive Denials in the Denials Management Work Queues for Medical Necessity, Late-Pick-Up/Notification and Readmission Denials that are entered by Utilization Review and Business Office. Responsible for writing appeal letters for Inpatient CMS (RAC/MAC) and Commercial late pick-ups, medical necessity, readmissions, and other requested inpatient denials as deemed clinically appropriate. The DS RN is responsible for reviewing clinical documentation and payer denials related to inpatient hospital stays to determine and articulate medical necessity. This role involves writing comprehensive and evidence-base letters for Inpatient Denials ensuring compliance with payer guidelines, regulatory requirements, and organizational policies. Maintain accurate documentation of all appeal activities within designated systems. Maintains accurate spreadsheets for retro denials to ensure resolution within required timeframes and logging of action e.g. no appeal, appeal level and final decision with revenue impact. Assists Utilization Review as necessary to ensure that documentation is entered and transmitted to insurance carriers within acceptable timeframes to comply with appeal deadlines. Provides feedback to Utilization Review that can help in preventing future denials and assists in maintaining good communication and process flow between the 2 departments. Track and monitor denials and appeal outcomes to identify trends and opportunities for process improvement. Participates in root cause analysis for overturned and upheld appeals. Works with departments and providers to implement corrective actions to minimize lost revenue due to denials and rejections. Coordinates RAC appeals for complex case reviews for medical necessity, including determining if appeal is appropriate and communicating with vendor to ensure timely filing of same. Performs writing of RAC/MAC appeals at appropriate levels and documenting status. Maintains confidentiality of all materials handled within the Network/Entity as well as the proper release of information. Complies with Network and departmental policies regarding issues of employee, patient and environmental safety and follows appropriate reporting requirements. Demonstrates/models the Network’s Service Excellent Standards of Performance in interactions with all customers (internal and external). Demonstrates Performance Improvement in the following areas as appropriate: Clinical Care/Outcomes, Customer/Service Improvement, Operational System/Process, and Safety. Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes and practices. Complies with Network and departmental policies regarding attendance and dress code. Demonstrates competency in the assessment, range of treatment, knowledge of growth and development and communication appropriate to the age of the patient treated. Stays abreast of CMS and payer guidelines, regulatory requirements, and organizational policies impacting the revenue cycle regarding medical necessity. Maintains relationships with third party medical review staff and other departments to assist in adjudicating cases. Other related duties as assigned.

PHYSICAL AND SENSORY REQUIREMENTS

Sitting for one to two hours at a time. Standing for up to 2 hours per day, up to 10 minutes at a time. Walk on all surfaces for up to 3 hours per day and climb stairs. Fingering and handling objects frequently, uses fingers to turn pages. Frequently uses hands to write and/or type. Rarely uses hands or fingers for firm grasping or twisting/turning. Frequently uses upper extremities to lift and carry object up to 10 lbs. Rarely may be required to lift, carry, push, and/or pull objects weighing up to 75 pounds. Occasionally stoops, bends, squats, kneels and reaches above shoulder level. Must have the ability to hear as it relates to normal conversations and high and low frequencies and to see as it relates to general and peripheral vision. Must have the ability to touch as related to telephone and computer keyboard.

EDUCATION

Graduate of an accredited professional nursing program. Registered nurse with current license to practice in the state.

TRAINING AND EXPERIENCE

Minimum of 2-5 years of clinical nursing experience in an acute care hospital setting required. 2-5 years’ experience in case management and/or utilization management preferred. Appeal writing experience and financial experience related to appeal processes with insurance providers preferred. Experience in the use of computer applications, and statistical analysis using a variety of tools such as EXCEL, EPIC reporting, and MSOffice, etc. required.

St. Luke's University Health Network is an Equal Opportunity Employer.

Founded in 1872, St. Luke’s University Health Network (SLUHN) is a fully integrated, regional, non-profit network of more than 23,000 employees providing services at 16 campuses and 350+ outpatient sites. With annual net revenue in excess of $4 billion, the Network’s service area includes 11 counties in two states: Lehigh, Northampton, Berks, Bucks, Carbon, Montgomery, Monroe, Schuylkill and Luzerne counties in Pennsylvania and Warren and Hunterdon counties in New Jersey. St. Luke’s hospitals operate the largest network of trauma centers in Pennsylvania, with the Bethlehem Campus being home to St. Luke’s Children’s Hospital. SLUHN is the only Lehigh Valley-based health care system to earn Medicare’s five-star ratings (the highest) for quality, efficiency and patient satisfaction. It is both a Leapfrog Group and Healthgrades Top Hospital and a Newsweek World’s Best Hospital. The Network’s flagship University Hospital has earned the 100 Top Major Teaching Hospital designation from Premier 13 times total and eleven years in a row, including in 2023 when it was identified as THE #4 TEACHING HOSPITAL IN THE COUNTRY. In 2021, St. Luke’s was identified as one of the 15 Top Health Systems nationally. St. Luke’s is the ONLY health care institution in the Lehigh Valley to be named a Top Workplace regionally repeating the exclusive honor for the third year in a row. Also, for the third straight year, St. Luke’s has been a Top Workplaces in the Philadelphia Region by the Philadelphia Inquirer, ranking 9th in the large employer category for 2025 and the only health care system in PA to receive this award. In 2025, St. Luke’s was recognized as a national Top Workplaces by USA Today, three years in a row, including the 3rd best health care system in the nation in 2023 and 2024. Lastly, in 2025, St. Luke’s was named a Top Workplace in New Jersey for the third year in a row.

Learn More Here.