RN Denials & Appeals Specialist | Reimbursement Strategy

ERISA Recovery, Inc.; Plano (TX); On-site; USD 80,000 - 110,000; Full time

Benefits offered by this job

401(k) + company match

Paid time off

Paid lunches

Job summary

ERISA Recovery, Inc. in Plano, TX, seeks an experienced Registered Nurse (RN) to move beyond bedside care into utilization management and clinical review.

You will analyze denied claims, perform medical necessity reviews for inpatient and outpatient cases, and develop high-quality clinical appeals with peer-to-peer support. Collaborating with physicians, case managers, and UR teams, you'll resolve issues around authorizations and pre-certifications while tracking denial trends to drive process

Qualifications

• Active RN license is required.
• 3–5+ years of experience in ER Case Management or related field.

Responsibilities

• Analyze denied claims and clinical documentation to identify appeal opportunities.
• Perform medical necessity reviews for inpatient and outpatient cases.
• Develop and submit high-quality clinical appeals and support peer-to-peer reviews.
• Apply InterQual, MCG, and McKesson in case evaluations.
• Collaborate with physicians, case managers, and utilization review teams.
• Resolve issues related to authorizations, pre-certifications, and continued stay reviews.
• Track denial trends and contribute to process improvement initiatives.

Skills

RN license

Utilization management

Clinical review

Denial appeals

Medical necessity criteria

InterQual

MCG

Payer guidelines

Clinical judgment

Analytical skills

Tools

InterQual

MCG (Milliman)

McKesson

Job description

ERISA Recovery, Inc. in Plano, TX, seeks an experienced Registered Nurse (RN) to move beyond bedside care into utilization management and clinical review.

You will analyze denied claims, perform medical necessity reviews for inpatient and outpatient cases, and develop high-quality clinical appeals with peer-to-peer support. Collaborating with physicians, case managers, and UR teams, you'll resolve issues around authorizations and pre-certifications while tracking denial trends to drive process