Utilization Review RN — Denials & Appeals (Inpatient)

Capital Health; Trenton, Northern (NJ, KY); Hybrid; USD 87,000 - 120,000; Full time

Benefits offered by this job

Medical Plan

Prescription drug coverage

Dental Plan

Vision Plan

Flexible Spending Account

Job summary

Capital Health in Trenton, NJ, seeks a Clinical Denials Utilization Review RN for a full-time day shift to manage inpatient utilization for third-party reimbursement, denials, appeals, and clinical audits. The role requires RN licensure, 5+ years nursing, and 3+ years in case management with UR, discharge planning, and outcomes management.

The position collaborates with HIM and billing, maintains audit records, and contributes to performance improvement initiatives.

Qualifications

• Graduation from an accredited School of Registered Nursing.
• Five years' nursing experience.
• Three years' experience in case management including utilization review, discharge planning, outcomes management, assessment, care planning, and/or care coordination.

Responsibilities

• Monitors inpatient utilization in accordance with standards, Regulations and payer contracts.
• Supports denial and appeal process for department.
• Interfaces with HIM and billing to coordinate clinical components for reimbursement.
• Maintains records of utilization audits and prepares reports for authorities.
• Oversees denial life cycle and updates denials in UR software.

Skills

Utilization review

Discharge planning

Care coordination

CMS guidelines

Audit compliance

Education

RN degree

Tools

Utilization review software

EMR software

Microsoft Word

Microsoft Excel

Outlook

Job description

Capital Health in Trenton, NJ, seeks a Clinical Denials Utilization Review RN for a full-time day shift to manage inpatient utilization for third-party reimbursement, denials, appeals, and clinical audits. The role requires RN licensure, 5+ years nursing, and 3+ years in case management with UR, discharge planning, and outcomes management.

The position collaborates with HIM and billing, maintains audit records, and contributes to performance improvement initiatives.