Job Summary:

Assumes responsibility for managing inpatient denials for all payers related to medical necessity and clinical validation audits, and coordinates the appeal process with physicians, coding, third party payers, and third party auditors. Assists the case managers with utilization review issues, and provides recommendations for process improvement in the areas of utilization review and denial management. Other duties as assigned.

EXPERIENCE DESCRIPTION:

A minimum of 5 years of acute care nursing experience is required. Prior utilization management, insurance background, and denial management experience is preferred.

EDUCATION DESCRIPTION:

Bachelor's degree is required. Professional knowledge of nursing theory and practice at a level normally acquired through completion of a minimum of four years education at an accredited School of Nursing in order to be eligible for licensure as a Registered Nurse is requi...