Clinical Denials and Appeals Nurse Specialist

Job Description

Join Our Team as a Clinical Denials and Appeals Nurse Specialist! At Tri Health, we are driven by a shared commitment to excellence and innovation in healthcare. We believe that every test, analysis, and result plays a vital role in our mission to provide the highest standard of care to our patients.

Join us in our mission to advance healthcare and improve lives. Apply today and be part of a team that is passionate about making a difference. We offer career growth opportunities, and a comprehensive benefits package.

Tri Health Patient Accounting – at 4686 Forest Ave, Cincinnati, OH 45212

• Full‑time (72 hours bi‑weekly)
• Day shift – 7:00am‑3:30pm or 8:00am‑5:00pm
• No weekend or holiday rotation

We offer a comprehensive benefits package, including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement.

• Associate's Degree or Diploma in Nursing (Required)
• New hires required to obtain BSN within 5 years of hire (Required)
• 5 – 7 years clinical RN experience in a clinical setting (Required)
• 2 – 3 years utilization management, appeals, or revenue cycle experience (Preferred)
• MCG/Inter Qual; payer rules/CMS; revenue cycle & UM; ICD/CPT/DRG basics; appeals structures.
• Clinical review; root cause analysis; persuasive writing; cross‑functional communication; time management; EMR/Excel proficiency.
• Apply criteria to define level of care; autonomous decision‑making; regulatory compliance; outcome influence; cross‑department collaboration.
• Registered Nurse Upon Hire Required and
  • Other Accredited Case Manager & Care Manager (ACM & CMC & CCM) Preferred
  • Other Professional Utilization Review (CPUR) Preferred
  • Other Certified Clinical Documentation Specialist (CCDS) Preferred
  • Other Certified Revenue Cycle Rep (CRCR) Preferred

The Clinical Denials and Appeals Nurse Specialist functions as a liaison to numerous departments including physicians, utilization and case management to appeal denied claims, complete retrospective reviews and compile data for trends and patterns identified to support process improvement. This position is responsible for managing appeal processes, reviewing and understanding clinical guidelines (like Milliman/Inter Qual) and communicating with internal and external stakeholders.

Team member works independently with a high level of autonomy and decision making.

• Conducts prospective, concurrent, and retrospective reviews to determine appropriate level of care (inpatient, observation, outpatient). Applies clinical guidelines (Inter Qual/Milliman) to validate medical necessity for admission and continued stay. Communicates with providers and other departments regarding documentation, admission orders, and status changes. Ensures compliance with government and commercial payer requirements.
• Reviews medical necessity, pre‑/post service denials, and payer audit findings. Performs comprehensive clinical record reviews to ensure documentation accuracy and integrity. Prepares written appeals using documentation, clinical criteria, research, coding guidelines, and contract language. Coordinates peer‑to‑peer reviews as appropriate. Documents all appeal actions in host systems and monitors deadlines to ensure timely filings.
• Tracks and analyzes denial trends to identify root causes and collaborate on prevention strategies. Works with IT/Revenue Cycle to enhance reporting automation and standardization. Communicates discrepancies between payer policies and internal processes.
• Provides clear, concise correspondence with payers, physicians, case management, and revenue cycle partners. Escalates complex cases and policy conflicts when needed. Supports education for staff and providers on documentation and criteria requirements.
• Maintains up‑to‑date competency in UM, CMS regulations, payer requirements, and appeals processes. Participates in quality initiatives and regulatory readiness activities. Demonstrates Tri Health SERVE standards in all interactions.

• Concentrating – Consistently
• Continuous Learning – Frequently
• Hearing:
  Conversation – Frequently
• Hearing:
  Other Sounds – Rarely
• In…