Senior RN Denials & Appeals Supervisor

Care New England; Providence (RI); On-site; USD 90,000 - 120,000; Full time

Job summary

Care New England seeks a Clinical Denial Supervisor to manage hospital denial and appeal processes, leveraging InterQual and Medicare guidelines. The role requires coordinating with care management leadership, physicians, and payer contacts to secure reimbursement and reduce write-offs.

The position emphasizes education of staff and ongoing process improvement, with responsibilities spanning audits, documentation, and regulatory compliance tied to payer denials.

Qualifications

• Bachelor’s degree in nursing required or preferred; RN licensure in RI.
• Minimum 2 years in hospital case management with denials/appeals experience.
• CCM or ACM certification required within two years of hire if not already held.

Responsibilities

• Research clinical denials related to referral and medical necessity; initiate appeals.
• Submit detailed, customized appeals to payers per guidelines.
• Initiate peer-to-peer reviews and communicate with payers/organizations.
• Monitor and follow up on appeals through the process; document diligently.
• Educate staff, physicians, and payers on reimbursement issues and documentation practices.
• Coordinate status determinations using InterQual and Medicare guidelines.

Skills

InterQual/MCG knowledge

EMR systems experience

Staff training & education

Case management

Education

Bachelor’s degree in nursing

RI State Nursing Licensure

CCM/ ACM certification within 2 years

Job description

Care New England seeks a Clinical Denial Supervisor to manage hospital denial and appeal processes, leveraging InterQual and Medicare guidelines. The role requires coordinating with care management leadership, physicians, and payer contacts to secure reimbursement and reduce write-offs.

The position emphasizes education of staff and ongoing process improvement, with responsibilities spanning audits, documentation, and regulatory compliance tied to payer denials.