Full employer posting
Job Requirements Under limited supervision, assists the Director, Clinical Appeals & Denials Analytics in supporting the daily operations and oversight of the Denials Prevention Team. Serves as the lead clinical resource and subject matter expert for reimbursement denials, utilization management principles, regulatory requirements, and clinical documentation standards. Maintains an active workload while providing guidance, mentorship, education, quality oversight, and operational support to team members.
Collaborates with physicians, physician advisors, revenue cycle leadership, utilization management, case management, coding, CDI, and patient financial services to identify denial trends, implement denial prevention strategies, and optimize reimbursement outcomes across the health system. The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification.
They are not to be construed as an exhaustive list of all
performed. Demonstrates comprehensive expertise in clinical denial management, payer audits, root cause analysis, reimbursement processes, and regulatory compliance related to utilization management. Serves as the primary resource and escalation point for Denials Prevention RNs.
Performs prospective and retrospective clinical audits/root cause analyses to identify opportunities for documentation improvement, denial prevention, front-end workflow optimization and back-end pre-bill review. Develops mitigation strategies and collaborates with physicians, physician advisors, physician leadership, CDI specialists, coding professionals, case management, utilization management, and revenue cycle stakeholders to implement strategies that optimize reimbursement outcomes.
Assists in monitoring denial trend, reimbursement risks, and payer performance patterns across the health system. Develop reports, educational materials, and presentations related to denial trends, payer activity, and member organization performance metrics. Participates in recruitment and candidate selection.
Provides onboarding, orientation, mentoring, and ongoing education to new and existing staff members. Assists leadership with staff competencies and professional development. Provides feedback regarding team member performance.
Perform all other related duties as assigned. Work Experience Required Bachelor of Science in Nursing (BSN). Currently active Registered Nurse license in the State of Maryland.
Certification in Case Management, Utilization Management, Revenue Cycle, CDI, or related specialty. Five (5) years of professional nursing experience in an acute care setting. Three (3) years of experience in clinical denials management, utilization review, case management, or revenue cycle operations.
Demonstrated expertise in denial appeals, utilization management principles, and reimbursement regulations. Preferred Lead, preceptor, educator, or supervisory experience. Experience with denial analytics, auditing, and performance improvement initiatives.
Experience in CDI or coding
days shift
About the role
Under limited supervision, assists the Director, Clinical Appeals & Denials Analytics in supporting the daily operations and oversight of the Denials Prevention Team. Serves as the lead clinical resource and subject matter expert for reimbursement denials, utilization management principles, regulatory requirements, and clinical documentation standards.