Clinical Appeals RN - FT - Day - Revenue Integrity & Denials Mgmt Lawrenceville NJ

Benefits

Additional Information

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time). Pay Range: $92,289.60 - $120,577.60 Scheduled Weekly Hours: 40 Position Overview Responsible for clinical review, development, and submission of inpatient and outpatient clinical appeals for denied hospital claims. This role applies clinical expertise, medical record analysis, MCG clinical criteria, and payer-specific clinical policies to support medical necessity, patient status, and other clinical determinations in order to maximize appropriate reimbursement and reduce avoidable denials. MINIMUM REQUIREMENTS Education: Graduate of an accredited school of nursing required. Experience: Three years' clinical nursing experience required. Experience in utilization review, case management, clinical appeals, CDI, or denial management required. Other Credentials: AHA BLS - Healthcare Provider,Registered Nurse - NJ CPR Requirements: Requires ACLS (or must obtain within 6 months of hire date) if assigned to: Critical Care/Intermediate/Telemetry, Emergency Rooms, Pediatrics/Pediatrics Emergency Room, Labor & Delivery, Surgical Services (not to include Perioperative), Interventional Procedures, Observation. Requires NRP (or must obtain within 6 months of hire date) if assigned to: Maternity Services Requires PALS (or must obtain within 6 months of hire date) if assigned to: Emergency Rooms, Infant Follow-Up, Surgical Services (only PACU & Same Day Surgery), Pediatrics/Pediatric ED. Knowledge and Skills: Required familiarity with MCG clinical criteria for inpatient and outpatient medical necessity and patient status determinations. Required familiarity with payer-specific clinical policies, medical necessity guidelines, and appeal requirements. Strong understanding of inpatient and outpatient medical necessity and patient status criteria. Ability to analyze medical records and synthesize clinical evidence into clear, persuasive written arguments. Strong written and verbal communication skills. Ability to work collaboratively with physicians, physician advisors, CDI, UR, and non-clinical denial staff. Proficiency with hospital information systems and Microsoft Office applications. Strong written and verbal communication skills. Ability to work collaboratively with physicians, physician advisors, CDI, UR, and non-clinical denial staff Special Training: Mental, Behavioral and Emotional Abilities: Proficiency with hospital information systems and Microsoft Office applications Usual Work Day: 12 Hours Reporting Relationships Does this position formally supervise employees? No If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager. ESSENTIAL FUNCTIONS Conducts comprehensive clinical review of denied inpatient and outpatient claims using MCG criteria and payer clinical policies to determine appeal viability. Prepares written clinical appeals and rebuttals supported by medical record documentation, MCG criteria, and payer-specific policy language Collaborates with Utilization Review, Case Management, CDI, physicians, and physician advisors to support appeal development Prepares appeal packets, ensuring completeness, accuracy, and compliance with payer submission requirements and deadlines Maintains clear and concise documentation in hospital systems related to appeal actions and clinical rationale. Identifies recurring clinical denial trends related to MCG criteria application or payer policy interpretation and escalates findings to leadership. Maintains current knowledge of MCG updates, payer policy changes, and industry best practices Participates in audits, education initiatives, and process improvement activities related to clinical denials and appeals Performs other duties as assigned and adapts to changing departmental demands. PHYSICAL DEMANDS AND WORK ENVIRONMENT Frequent physical demands include: Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Squat/kneel/crawl , Wrist position deviation , Pin