RN Clinical Denials Supervisor

About the role

Under the general supervision of Care Management Leadership, the Clinical Denial Supervisor performs advanced clinical denial management for hospital care. The role involves comprehensive review of clinical documentation, writing compelling arguments based on medical policies, and submitting timely appeals. Responsibilities also include audit‑related and compliance duties, problem identification and resolution to ensure accurate billing, education of staff and physicians on documentation practices, and communication of denial and appeal activity to stakeholders. The supervisor monitors trends, reports findings to Revenue Cycle Management, and independently plans and organizes activities that directly impact hospital and physician reimbursement, supporting Care New England’s mission, vision, and values.

Responsibilities

• Research clinical denials related to referral, medical necessity, case management, and non‑covered services.
• Initiate appeals with insurers appropriately and submit detailed, customized appeals in accordance with Medicare, Medicaid, third‑party guidelines, and CNE policies.
• Initiate Peer‑to‑Peer reviews and communicate thoroughly with payers and peer review organizations to resolve denials.
• Monitor and follow up on appeals throughout the entire process.
• Maintain accurate, clear, and timely documentation related to denied cases.
• Develop, implement, and evaluate processes to ensure accurate and timely collection of information.
• Serve as a resource for hospital case management departments regarding concurrent denials.
• Assist the Care Management department in implementing strong processes to prevent claim denials and facilitate successful appeals.
• Educate staff, physicians, and payers on reimbursement issues, clinical protocols/criteria, insurance plan changes, regulations, and process improvements.
• Coordinate appropriate status determinations using InterQual and Medicare guidelines.
• Identify denial patterns, escalate to management with sufficient information for follow‑up or root‑cause resolution.
• Tabulate financial gains of the position and identify opportunities for improvement.
• Review payer communications, identify reimbursement risk related to medical policies and prior‑authorization requirements, and escalate issues to clinical stakeholders, managed‑care contracting, and Revenue Cycle leadership.
• Submit retro‑authorizations in accordance with payer requirements in response to authorization denials.
• Provide clinical support for complex billing and follow‑up workflows, including RAC correspondence, appeal processing, and other audit reviews.
• Perform advanced billing procedures requiring extensive communication with other departments, including consecutive account processing and Medicare A/B split claims processing.
• Support the director in related responsibilities as requested.
• Respond to patient and family inquiries regarding denials.
• Maintain expertise and continue self‑education by attending conferences, workshops, and interdisciplinary meetings.
• Utilize local, regional, and national forums to continuously enhance expertise and knowledge base.
• Participate in professional organizations and committees.

Requirements

• Bachelor’s degree in nursing preferred; minimum of 2 years job‑related experience or equivalent required.
• RI State Nursing Licensure required; graduation from an accredited nursing program.
• Two years recent experience in hospital case management with demonstrated competency in InterQual and/or MCG and Medicare rules and regulations.
• Knowledge of and comfort with EMR functionality.
• Previous management of clinical appeals preferred.
• Certification in Care Management (CCM or ACM) required; if not already held, certification must be obtained within two years of hire.

About Us

Care New England Health System (CNE) and its member institutions—including Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group—are a trusted, integrated health‑care organization. CNE advances medical research, attracts top specialty‑trained physicians, delivers renowned services and innovative programs, and engages communities in essential health and end‑of‑life conversations. The system is dedicated to transforming the future of health care and ensuring the health of the individuals and communities it serves.