RN Post-Claims Denials & Appeals Analyst

Hialeah Hospital; Florida; On-site; USD 65,000 - 95,000; Full time

Job summary

Hialeah Hospital is seeking a Post-Claims Denial Analyst RN to investigate, analyze, and resolve clinical denied medical claims to optimize reimbursement. The role requires applying payer policies and regulatory knowledge to determine root causes of denials and support medical necessity.

Responsibilities include reviewing denied and underpaid claims, analyzing documentation, submitting appeal letters with evidence-based guidelines, and tracking outcomes to report financial impact.

Qualifications

• Active unrestricted Registered Nurse license.
• 2-5 years of clinical experience (acute care, utilization review, case management, or similar role).
• Experience in medical claims review, appeals, or denial management within a hospital, managed care, or health system.
• Strong understanding of medical necessity, clinical guidelines, coding principles, and payer regulations.
• Knowledge of CMS guidelines, Medicare Advantage, Medicaid, and commercial payer policies.

Responsibilities

• Review denied and underpaid claims to determine the clinical and regulatory validity of denials.
• Analyze medical records and clinical documentation to support medical necessity, level of care, and correct coding.
• Submit appeal letters with supporting clinical documentation and evidence-based guidelines.
• Identify denial and recommend process improvements.
• Maintain up-to-date knowledge of Medicare, Medicaid, and commercial payer requirements.
• Track appeal outcomes and maintain detailed records to report recovery trends and financial impact.

Skills

Active RN license

Job description

Hialeah Hospital is seeking a Post-Claims Denial Analyst RN to investigate, analyze, and resolve clinical denied medical claims to optimize reimbursement. The role requires applying payer policies and regulatory knowledge to determine root causes of denials and support medical necessity.

Responsibilities include reviewing denied and underpaid claims, analyzing documentation, submitting appeal letters with evidence-based guidelines, and tracking outcomes to report financial impact.