RN Denials & Appeals Lead — Revenue Recovery

AHMC HealthCare; San Gabriel (CA); On-site; USD 80,000 - 100,000; Full time

Job summary

AHMC HealthCare is seeking a Denials Case Manager, RN in San Gabriel, CA. This role involves appealing denials, working with revenue cycle teams, and ensuring compliance with medical necessity standards. Requires a graduate of an accredited RN School and experience in Utilization Management. Strong negotiation skills and a solid understanding of reimbursement processes, including Medicare and Medi-Cal, are essential. This position is key to maximizing timely reimbursement and implementing denial prevention strategies.

Qualifications

• Four years recent acute care experience in a critical care setting (preferred).
• Two years Utilization Management/Case Management experience.
• Working knowledge of reimbursement related to Medicare, Medi-Cal, Shared Risk, and Managed Care.

Responsibilities

• Appeals all denials using InterQual criteria and medical necessity.
• Collaborates with Case Managers, Physicians, and Finance teams for compliance.
• Tracks responses to appeals and follows up as appropriate.

Skills

Negotiation skills

Problem-solving

Clinical knowledge

Education

Graduate of an accredited RN School of Nursing

BSN preferred

Tools

MCG

Job description

AHMC HealthCare is seeking a Denials Case Manager, RN in San Gabriel, CA. This role involves appealing denials, working with revenue cycle teams, and ensuring compliance with medical necessity standards. Requires a graduate of an accredited RN School and experience in Utilization Management. Strong negotiation skills and a solid understanding of reimbursement processes, including Medicare and Medi-Cal, are essential. This position is key to maximizing timely reimbursement and implementing denial prevention strategies.