Clinical Financial Case Manager RN
New
United States, first shiftFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- Minimum 5 years of clinical nursing experience; At least 2 years of experience specifically in claim denial escalation and advanced clinical appeals
- Required Skills
- EHR
Requirements
- Bachelor’s Degree in Nursing (BSN)
- Active, unrestricted Registered Nurse (RN) license
- Minimum 5 years of clinical nursing experience (utilization review, case management, prior authorization, or revenue cycle)
- At least 2 years of experience in claim denial escalation and advanced clinical appeals
- Knowledge of medical necessity criteria (MCG/InterQual)
- Familiarity with ICD-10, CPT/HCPCS coding concepts, and healthcare compliance
- Experience working with EHR systems and payer portals
- Strong analytical, communication, and presentation skills
Responsibilities
- Independently review and manage complex clinical denial cases, determining medical necessity and appropriate escalation pathways.
- Conduct advanced clinical appeals, interpreting payer contracts, guidelines (MCG/InterQual), and regulatory requirements.
- Monitor, analyze, and report on denial trends across commercial and governmental payers.
- Assist leadership in quality assurance activities, workflow evaluation, and performance monitoring.
- Support team coordination by acting as a clinical resource and providing coaching.
- Collaborate with cross-functional teams to improve denial management processes and technology adoption.
- Stay current on payer policy changes and regulatory updates.
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