Utilization Review RN: Denials & Appeals Specialist

Capital Health (US); United States; On-site; USD 9,900 - 120,000; Full time

Benefits offered by this job

Medical Plan

Dental Plan

Vision Plan

Retirement Savings Plan

Paid Time-Off Program

Life Insurance

Disability Insurance

Job summary

Capital Health is seeking a Registered Nurse with strong utilization review and case management experience to support inpatient reimbursement and appeals. The role emphasizes adherence to CMS guidelines and coordination with HIM and billing teams.

Ideal candidate has 5+ years nursing, 3+ years in case management, and experience with UR software and EMR systems. Inpatient denial appeal experience is a plus. Benefits include comprehensive plan options and PTO.

Qualifications

• RN license required (NJ) and BSN preferred.
• 5 years’ nursing experience; 3 years in case management including UR, discharge planning, outcomes management, or care coordination.
• Inpatient denial appeal experience preferred; CMS guidelines knowledge required.

Responsibilities

• Perform UR functions for inpatient cases to support third party reimbursement, denials, appeals and clinical audits.
• Support performance and quality improvement activities within the department.
• Prepare and submit appeals timely and ensure completion of UR inpatient appeal process.

Skills

RN

Case management

Utilization review

Discharge planning

CMS guidelines

EMR/UR software

Education

Graduation from an accredited School of Registered Nursing

Tools

Utilization review software

EMR

Job description

Capital Health is seeking a Registered Nurse with strong utilization review and case management experience to support inpatient reimbursement and appeals. The role emphasizes adherence to CMS guidelines and coordination with HIM and billing teams.

Ideal candidate has 5+ years nursing, 3+ years in case management, and experience with UR software and EMR systems. Inpatient denial appeal experience is a plus. Benefits include comprehensive plan options and PTO.