Job Description

POSITION SUMMARY

Under the director of the CBO Director, the Post-Claims Denial Analyst RN is responsible for investigating, analyzing, and resolving clinical denied medical claims to optimize reimbursement. This role leverages clinical expertise and knowledge of payer policies, government regulations, and revenue cycle operations to determine root causes of denials.

KEY RESPONSIBILITIES

• Review denied and underpaid claims to determine the clinical and regulatory validity of denials.
• Analyze medical records and clinical documentation to support medical necessity, level of care, and correct coding.
• Submit appeal letters with supporting clinical documentation and evidence-based guidelines.
• Identify denial and recommend process improvements.
• Maintain up-to-date knowledge of Medicare, Medicaid, and commercial payer requirements.
• Track appeal outcomes and maintain detailed records to report recovery trends and financial impact.

QUALIFICATIONS AND EXPERIENCE

• Active unrestricted Registered Nurse license.
• Minimum 2-5 years of clinical experience (acute care, utilization review, case management, or similar role).
• Experience in medical claims review, appeals, or denial management within a hospital, managed care, or health system.
• Strong understanding of medical necessity, clinical guidelines, coding principles, and payer regulations.
• Knowledge of CMS guidelines, Medicare Advantage, Medicaid, and commercial payer policies.