Clinical Nurse Specialist
$68,000–$100,000 year
Remote · Delray Beach, Florida, United States
Job Summary
Clinical Nurse Specialist to resolve complex clinical denials by translating medical documentation into clear, evidence-based appeal arguments that drive reimbursement outcomes. Analyze denial trends, apply clinical guidelines (e.g., InterQual, Milliman), prepare and enhance appeals using internal tools (e.g., DOCIQ), assign denial root causes, and collaborate with operations to meet performance goals. Strong clinical reasoning, proficiency with EMRs, and ability to interpret payer guidelines are required. Active RN or LPN license and prior experience in utilization review or clinical denials are preferred.
Required Qualifications
- Active LPN or RN license (required)
- 1+ year experience in utilization review, case management, or clinical denials
- 1+ year experience resolving hospital clinical denials
- Acute care clinical experience preferred
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