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Hospital Appeals Specialist, RN
CentraState Healthcare System. Complete clinical review of denied services .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical review, denial management, and appeals processes, with a strong focus on improving operational and financial outcomes within the revenue cycle. Proficient in analyzing claims data and developing workflows to enhance departmental efficiency and effectiveness.
Highest-signal resume keywords
Active NJ Registered Nurse (RN) LicenseUtilization Review ExperienceCase Management ExperienceClinical Documentation Improvement ExperienceDenials/Appeals or Revenue Cycle Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Clinical ReviewDenial ManagementClaims Data AnalysisWorkflow DevelopmentBilling AdjustmentsRoot Cause AnalysisRevenue Integrity ManagementMedical Record AuditsAppeal Letter PreparationProductivity and Quality Standards
Soft Skills
Relationship ManagementIndependent WorkCollaborationFacilitationCommunication
Certifications & Qualifications
Bachelor of Science in Nursing (BSN)
Industry Keywords
DenialsAppealsRevenue CycleAcute CareExplanations of BenefitsNon-Governmental Insurance ClaimsClinical OutcomesOperational OutcomesFinancial OutcomesDepartment Workflow Processes
About the role
Key responsibilities & impact- Complete clinical review of denied services
- Prepare clinical discussion and appeal letters for payers
- Develop the denials department and create workflows for in-house denial submission
- Develop an in-house appeals department
- Determine root causes of denials
- Establish and manage relationships with AHS leaders
- Facilitate regular meetings to present and review denial information
- Manage department workflow processes and follow productivity and quality standards
- Ensure denied claims are submitted and followed up in a timely manner
- Interpret explanations of benefits for non-governmental insurance claims
- Analyze hospital claims data for contractual underpayments, denials, and billing errors
- Make billing adjustments based on denial outcomes
- Submit information to payers and follow up on in-house-submitted denials
- Manage Revenue Integrity and denials work queues
- Provide monthly denial reports to the department manager, clinical departments, and case management
- Collaborate with leadership and staff inside and outside the revenue cycle team to improve clinical, operational, and financial outcomes
Requirements
What you’ll need- Active NJ Registered Nurse (RN) license
- Bachelor of Science in Nursing (BSN) preferred
- 3–5+ years of clinical experience; acute care preferred
- Experience in Utilization Review
- Experience in Case Management
- Experience in Clinical Documentation Improvement
- Experience in Medical Record Audits
- Experience in Denials/Appeals or Revenue Cycle
- Ability to work independently
Benefits
Comp & perks- Medical, Dental, Vision, Prescription Coverage
- Life & AD&D Insurance
- Short-Term and Long-Term Disability, with options to supplement
- 403(b) Retirement Plan with employer match and additional non-elective contribution
- PTO & Paid Sick Leave
- Tuition Assistance, Advancement & Academic Advising
- Parental, Adoption, Surrogacy Leave
- Backup and On-Site Childcare
- Well-Being Rewards
- Employee Assistance Program (EAP)
- Fertility Benefits and Healthy Pregnancy Program
- Flexible Spending & Commuter Accounts
- Pet, Home & Auto, Identity Theft and Legal Insurance