Denial and Appeals RN / Clinical Resource Management

Location

1290 Silas Deane Highway, Wethersfield, CT 06109

Schedule

Monday through Friday, 7:00 AM – 3:30 PM. No holidays or weekends.

About the Role

The Denial and Appeals Nurse is an integral part of the Care Management team, focusing on the management of the payer denial and appeals process. This role involves appealing inappropriate denials through all levels of the appeals process and working autonomously to manage a high volume of complex cases across all Hartford HealthCare system hospitals.

Responsibilities

• Follow standard work processes to manage denials and appeals.
• Ensure activities are completed within regulatory and payer timeframes.
• Develop and maintain collaborative relationships with internal and external stakeholders to obtain additional information for clinical appeals and resolve issues.
• Partner with the Medical Director and Physician Advisor staff to compose factually sound appeal letters using clinical documentation and contract language.
• Maintain all documentation associated with appeals to comply with regulatory standards and timeframes, ensuring accurate and complete records in the appropriate database.
• Assist in analysis and documentation of root causes for denials.
• Provide education to stakeholder groups on findings, analysis, and mitigation strategies.
• Work with a multi-disciplinary team to identify denial and appeal trends and support the development of performance improvement strategies.
• Perform other duties as assigned.

Requirements

• Current State of Connecticut RN license (required).
• Bachelor of Science in Nursing (preferred).
• Five years of relevant case management, utilization management, or managed care experience.
• Thorough understanding of Medicare, Medicaid, and Commercial reimbursement methodologies (preferred).
• CCM (Certified Case Manager), CPUM (Certified Professional in Utilization Management), or other relevant certification (preferred).

Skills

• Strong interpersonal and written/oral communication skills.
• Ability to maintain a positive attitude in a fast-paced environment.
• Strong influencing and negotiation skills.
• Critical thinking, astute assessment, and confident decision-making.
• Knowledge of Interqual, MCG, or equivalent criteria and reimbursement guidelines.
• Proficiency in Microsoft Office (Word, Excel, PowerPoint).
• Experience with EPIC.

Benefits

Hartford HealthCare offers a competitive benefits program designed to ensure work/life balance, along with opportunities for career development and growth across locations in Connecticut.