RN Denials & Appeals Specialist — Medical Necessity

St. Luke's University Health Network; Allentown (Lehigh County); On-site; USD 75,000 - 105,000; Full time

Job summary

St. Luke’s University Health Network is seeking a Denials Management Specialist RN to review clinical documentation and payer denials related to inpatient hospital stays and determine medical necessity.

You will write comprehensive, evidence-based appeal letters for CMS RAC/MAC and commercial denials while ensuring compliance with payer guidelines and organizational policies. The role involves tracking denials, maintaining documentation, and collaborating with Utilization Review and other

Qualifications

• Graduate of an accredited professional nursing program.
• Registered nurse with current license to practice in the state.
• Minimum of 2-5 years of clinical nursing experience in an acute care hospital setting.
• Experience in case management and/or utilization management preferred.
• Appeal writing experience and financial experience with insurance providers preferred.

Responsibilities

• Review inpatient denials for medical necessity and payer guidelines.
• Write comprehensive appeal letters for inpatient denials (CMS RAC/MAC) and commercial denials.
• Maintain accurate documentation of all appeal activities in designated systems.
• Track denials and appeal outcomes to identify trends and process improvements.
• Coordinate with Utilization Review and other departments to ensure timely filings.
• Maintain confidentiality and comply with organizational policies.

Skills

Clinical nursing

Utilization review

Appeal writing

Medical terminology

Analytical skills

Education

RN license (PA)

Accredited nursing program

Tools

EPIC

Excel

MS Office

Job description

St. Luke’s University Health Network is seeking a Denials Management Specialist RN to review clinical documentation and payer denials related to inpatient hospital stays and determine medical necessity.

You will write comprehensive, evidence-based appeal letters for CMS RAC/MAC and commercial denials while ensuring compliance with payer guidelines and organizational policies. The role involves tracking denials, maintaining documentation, and collaborating with Utilization Review and other