Job Description

Join Our Team as a Clinical Denials and Appeals Nurse Specialist!

At TriHealth, we are driven by a shared commitment to excellence and innovation in healthcare. We believe that every test, analysis, and result plays a vital role in our mission to provide the highest standard of care to our patients.

Join us in our mission to advance healthcare and improve lives. Apply today and be part of a team that is passionate about making a difference.

We offer career growth opportunities, and a comprehensive benefits package.

Location:

• TriHealth Patient Accounting – at 4686 Forest Ave, Cincinnati, OH 45212

Work Schedule:

• Full - Time (80 hours bi-weekly)

• Day shift – 7:00am-3:30pm or 8:00am-5:00pm

• No weekend or holiday rotation

Incentives & Benefits:

We offer a comprehensive benefits package, including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement.

https://careers.trihealth.com/what-we-offer/benefits

Job Requirements:

• Associate's Degree or Diploma in Nursing (Required)

• New hires required to obtain BSN within 5 years of hire (Required)

• 5 - 7 years clinical RN experience in a clinical setting. (Required)

• 2 - 3 years utilization management, appeals, or revenue cycle experience. (Preferred)

• MCG/InterQual; payer rules/CMS; revenue cycle & UM; ICD/CPT/DRG basics; appeals structures.

• Clinical review; root cause analysis; persuasive writing; cross-functional communication; time management; EMR/Excel proficiency.

• Apply criteria to define level of care; autonomous decision-making; regulatory compliance; outcome influence; cross-department collaboration.

• Registered Nurse Upon Hire Required and Other Accredited Case Manager & Care Manager (ACM & CMC & CCM) Preferred or Other Professional Utilization Review (CPUR) Preferred or Other Certified Clinical Documentation Specialist (CCDS) Preferred or Other Certified Revenue Cycle Rep (CRCR) Preferred

• The Clinical Denials and Appeals Nurse Specialist functions as a liaison to numerous departments including physicians, utilization and case management to appeal denied claims, complete retrospective reviews and compile data for trends and patterns identified to support process improvement. This position is responsible for managing appeal processes, reviewing and understanding clinical guidelines (like Milliman/InterQual) and communicating with internal and external stakeholders. Team member works independently with a high level of autonomy and decision making.
  

Job Responsibilities:

• Conducts prospective, concurrent, and retrospective reviews to determine appropriate level of care (inpatient, observation, outpatient). Applies clinical guidelines (InterQual/Milliman) to validate medical necessity for admission and continued stay. Communicates with providers and other departments regarding documentation, admission orders, and status changes. Ensures compliance with government and commercial payer requirements.

• Reviews medical necessity, pre-/post service denials, and payer audit findings. Performs comprehensive clinical record reviews to ensure documentation accuracy and integrity. Prepares written appeals using documentation, clinical criteria, research, coding guidelines, and contract language. Coordinates peer-to-peer reviews as appropriate. Documents all appeal actions in host systems and monitors deadlines to ensure timely filings.

• Tracks and analyzes denial trends to identify root causes and collaborate on prevention strategies. Works with IT/Revenue Cycle to enhance reporting automation and standardization. Communicates discrepancies between payer policies and internal processes.

• Provides clear, concise correspondence with payers, physicians, case management, and revenue cycle partners. Escalates complex cases and policy conflicts when needed. Supports education for staff and providers on documentation and criteria requirements.
• Maintains up-to-date competency in UM, CMS regulations, payer requirements, and appeals processes. Participates in quality initiatives and regulatory readiness activities. Demonstrates TriHealth SERVE standards in all interactions.

Working Conditions:
Concentrating - Consistently
Continuous Learning - Frequently
Hearing: Conversation - Frequently
Hearing: Other Sounds - Rarely
Interpersonal Communication - Consistently
Reading - Frequently
Sitting - Frequently
Standing - Occasionally
Stooping - Occasionally
Talking - Frequently
Thinking/Reasoning - Consistently
Use of Hands - Consistently
Color Vision - Frequently
Visual Acuity: Far - Occasionally
Visual Acuity: Near - Consistently
Walking - Rarely

TriHealth SERVE Standards and ALWAYS Behaviors:
At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following:

Serve: ALWAYS…
• Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
• Refrain from using cell phones for personal reasons in public spaces or patient care areas

Excel: ALWAYS…
• Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
• Offer patients and guests priority when waiting (lines, elevators)
• Work on improving quality, safety, and service

Respect: ALWAYS…
• Respect cultural and spiritual differences and honor individual preferences.
• Respect everyone’s opinion and contribution, regardless of title/role.
• Speak positively about my team members and other departments in front of patients and guests.

Value: ALWAYS…
• Value the time of others by striving to be on time, prepared and actively participating.
• Pick up trash, ensuring the physical environment is clean and safe.
• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.

Engage: ALWAYS…
• Acknowledge wins and frequently thank team members and others for contributions.
• Show courtesy and compassion with customers, team members and the community

Job Keywords: Registered Nurse, Nurse, Clinical Appeals and Denials