RN Clinical Denials & Appeals Lead

Women & Infants Hospital; Providence (RI); On-site; USD 85,000 - 115,000; Full time

Job summary

Women & Infants Hospital is seeking a Clinical Denial Supervisor to manage hospital care denials by reviewing documentation and drafting persuasive appeals in line with payer policies. This role collaborates with Care Management leadership to educate staff and improve billing accuracy.

The position focuses on reducing write-offs, coordinating denial reviews with physicians, and reporting denial trends to Revenue Cycle leadership for process improvements.

Qualifications

• Bachelor’s degree in nursing and a minimum of 2 years job-related experience or equivalent.
• RI State Nursing Licensure is required.
• Certification in Care Management (CCM or ACM) preferred; within two years of hire if not already held.

Responsibilities

• Research and manage clinical denials related to referral, medical necessity, and case management.
• Submit detailed, customized payer appeals per Medicare/Medicaid guidelines.
• Initiate Peer to Peer reviews and coordinate with payers and reviewers.
• Monitor appeals through completion and document outcomes clearly.
• Educate staff and physicians on documentation practices to prevent denials.
• Identify denial patterns and communicate trends to Revenue Cycle leadership.

Skills

InterQual knowledge

EMR proficiency

Payer negotiation

Education

Bachelor's degree in nursing

RI State Nursing Licensure

Tools

InterQual

MCG

EMR

Job description

Women & Infants Hospital is seeking a Clinical Denial Supervisor to manage hospital care denials by reviewing documentation and drafting persuasive appeals in line with payer policies. This role collaborates with Care Management leadership to educate staff and improve billing accuracy.

The position focuses on reducing write-offs, coordinating denial reviews with physicians, and reporting denial trends to Revenue Cycle leadership for process improvements.