Clinical Denials & Appeals Nurse Specialist (IP & OP)

Work Setup: Onsite | Night Shift

Job Summary

We are seeking a highly skilled Clinical Denials & Appeals Nurse Specialist to manage and resolve denied medical claims for both inpatient (IP) and outpatient (OP) services. The role involves reviewing clinical documentation, analyzing denial reasons, and preparing strong, evidence‑based appeals in accordance with U.S. healthcare regulations and payer guidelines.

Key Responsibilities

Denials and Appeals Management

• Review and evaluate denied claims, including payer policies and clinical documentation
• Perform medical necessity reviews using InterQual or MCG guidelines
• Prepare and submit detailed, well‑supported appeal letters
• Process retro‑authorizations as required
• Track appeals from submission through resolution
• Maintain accurate documentation of all a...