RN UTILIZATION SPECIALIST - DENIALS & APPEALS
On-siteMiddleburg Heights, Ohio, United States
Job Summary
Review patient medical records to ensure accurate documentation, proper level of care, and compliance with regulatory standards to prevent denials in the acute care setting. Collaborate with clinical staff, utilization specialists, denials management, and Physician Advisors to identify gaps in documentation and support case management, utilization review, or CDI initiatives. Maintain knowledge of ICD-10 coding guidelines, Medicare/Medicaid regulations, and MCG standards while utilizing Cerner (EMR) and MS Office tools. Requires current RN License by the Ohio State Board of Nursing and minimum three years of clinical nursing experience.
Required Qualifications
- Minimum of three years of clinical nursing experience
- Current RN License by the Ohio State Board of Nursing
Desired Qualifications
- Bachelor's degree in nursing (BSN) preferred
- experience in case management, utilization review, or CDI, in the acute care setting
- Knowledge of ICD-10 coding guidelines
- Knowledge of Medicare/Medicaid regulations
- Knowledge of MCG
- Knowledge of Cerner (EMR)
- Knowledge of MS office tools, such as Word, Excel, PowerPoint
- Ability to analyze complex medical records and identify gaps in documentation
- Strong verbal and written communication skills to interact with physicians and insurance payers
- Ability to collaborate with diverse teams including nurses, physicians, and administrative staff
- Preferred certification(s): ACM/ACM-RN, CCM, CMAC, CPHQ
Hiring someone like this?
Get your role in front of qualified candidates on Sorce.