Clinical Denials Utilization Review RN - FT - Day - Utilization Resource Management Pennington NJ
$86,965–$113,672 year
On-site · Pennington, New Jersey, United States
Job Summary
Clinical Denials Utilization Review RN focused on inpatient utilization, denial and appeals, and clinical audits for Capital Health. Responsible for UR processes for third-party reimbursement, contributing to Performance and Quality Improvement activities, preparing and submitting appeals timely, and coordinating with HIM and billing to ensure appropriate reimbursement. Requires RN licensure in NJ, five years nursing experience, and three years in case management/utilization review including discharge planning and care coordination; experience with inpatient denial appeal is preferred. Proficiency with CMS and payor guidelines, UR software/EMR, and strong data/documentation skills is expected. Frequent duties include monitoring denial life cycle, conducting retrospective audits, and supporting regulatory readiness with CMS, NJDHSS, DOBI, QIO, and DNV activities.
Required Qualifications
- Graduation from an accredited School of Registered Nursing
- Five years' experience in nursing
- Three years' experience in case management including utilization review, discharge planning, outcomes management, assessment, care planning, and/or care coordination
- Inpatient denial appeal experience preferred
- Knowledge of CMS guidelines, payor specific guidelines, contractual rules, and applicable clinical guidelines
- Proficient in word, excel, outlook, and other Utilization review software and EMR software
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