RN UTILIZATION SPECIALIST - DENIALS & APPEALS

Southwest General; Middleburg Heights (OH); On-site; USD 70,000 - 90,000; Full time

Job summary

Southwest General in Ohio is seeking an RN Utilization Specialist - Denials & Appeals to support clinical staff, utilization review, and physician advisors. You will review patient records to ensure documentation supports appropriate level of care and compliance with regulatory standards in the acute care setting.

The role emphasizes collaboration with nurses, physicians, and insurance payers, with a focus on preventing denials through accurate coding, documentation, and adherence to

Qualifications

• Bachelor’s degree in nursing (BSN) preferred.
• Minimum of three years of clinical nursing experience, with preference for case management, utilization review, or CDI.
• Knowledge of ICD-10 coding guidelines and Medicare/Medicaid regulations.
• Experience with Cerner EMR and MS Office tools (Word, Excel, PowerPoint).
• Ability to analyze complex medical records and identify gaps in documentation.
• Strong verbal and written communication to interact with physicians and payers.

Responsibilities

• Review patient medical records to ensure documentation supports appropriate level of care and regulatory compliance.
• Support clinical staff, utilization specialists, denials management, and physician advisors.
• Identify gaps in documentation to prevent denials and improve billing accuracy.
• Collaborate with nurses, physicians, and administrative staff to optimize care coordination.

Skills

Case management / utilization review

Documentation analysis

Verbal & written communication

Collaboration with diverse teams

Education

Bachelor’s degree in nursing (BSN) preferred

Tools

Cerner EMR

MS Office (Word, Excel, PowerPoint)

Job description

RN UTILIZATION SPECIALIST - DENIALS & APPEALS

Position summary: Utilization Specialist - Denials & Appeals will support the clinical staff, utilization specialists, denials management, and the Physician Advisors. This role will review patient medical records to ensure accurate documentation, proper level of care, and compliance with regulatory standards to prevent denials in the acute care setting.

MINIMUM QUALIFICATIONS

Education:

Bachelor’s degree in nursing (BSN) preferred

Required length and type of experience:

Minimum of three years of clinical nursing experience, with strong preference for experience in case management, utilization review, or CDI, in the acute care setting.

Knowledge of ICD-10 coding guidelines, Medicare/Medicaid regulations, MCG, Cerner (EMR), MS office tools, such as Word, Excel, PowerPoint.

Ability to analyze complex medical records and identify gaps in documentation.

Strong verbal and written communication skills to interact with physicians and insurance payers.

Ability to collaborate with diverse teams including nurses, physicians, and administrative staff.

Required licensure, certification or registry:

Current RN License by the Ohio State Board of Nursing.

Preferred certification(s): ACM/ACM-RN, CCM, CMAC, CPHQ.

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