Key skills
LeadershipCommunicationCritical Thinking
About this role
Role Overview
- Review and analyze medical records and denial rationale to develop clinically supported appeal arguments
- Interpret and apply clinical guidelines (e.g., InterQual, Milliman) to support medical necessity determinations
- Prepare, edit, and enhance appeals using internal tools (e.g., DOCIQ)
- Accurately assign denial root causes and complete nurse review reporting
- Identify denial trends and escalate insights to support prevention strategies and process improvement
- Document all case activity clearly within internal and client systems
- Participate in quality control reviews and provide feedback to improve appeal effectiveness
- Collaborate with operations and leadership to meet client expectations and performance goals
Requirements
- Active LPN or RN license (required)
- 1+ year experience in utilization review, case management, or clinical denials
- 1+ year experience resolving hospital clinical denials
- Strong clinical reasoning and critical thinking skills
- Ability to interpret medical documentation and payer guidelines
- Knowledge of utilization management and medical necessity criteria (e.g., InterQual, Milliman)
- Strong written communication skills for persuasive clinical appeals
- Attention to detail with ability to manage multiple priorities
- Proficiency with EMRs and healthcare systems.
Benefits
- Health insurance
- 401(k) matching
- Flexible working hours
- Paid time off
- Professional development opportunities