ERISA Recovery
Clinical Denials Specialist / RN – Medical Necessity Reviewer
We are seeking a highly skilled and experienced
Clinical Denials Specialist
with a strong background in
nursing (RN)
and a deep understanding of
medical necessity reviews
and
utilization management . In this role, you will work closely with internal case management teams, insurance providers, and clinical departments to analyze denied claims, prepare appeals, and ensure medical necessity documentation aligns with payer requirements.
About Us:
ERISA Recovery is a fast-growing company based in Dallas, TX, specializing in the recovery of aged and complex claims using the Federal ERISA appeals process. Our collaborative and innovative team offers an extraordinary opportunity for career growth in the ever-evolving revenue cycle industry.
Key Responsibilities
Review clinical documentation and denial letters to assess the reason for denial.
Conduct thorough
clinical reviews
for inpatient and outpatient cases.
Utilize
InterQual, MCG (Milliman), and McKesson review criteria
to determine medical necessity.
Draft and submit
clinical appeals
and
peer-to-peer reviews
as needed.
Collaborate with
ER case managers , physicians, and utilization review teams to gather and validate required documentation.
Evaluate and resolve issues related to
pre-certifications ,
authorizations , and
continued stay reviews .
Maintain up-to-date knowledge of payer policies, CMS guidelines, and industry standards.
Track denial trends and provide feedback for process improvement initiatives.
Qualifications
Registered Nurse (RN)
– active license required.
Minimum of
3-5 years
of clinical experience in inpatient and outpatient case management, including emergency room case management.
Strong experience with medical necessity criteria tools (InterQual, MCG/Milliman, McKesson Review) and pre-certifications, authorizations, and continued stay reviews.
Proven track record of
successful appeal writing
and overturning denials.
Familiarity with payer-specific guidelines and reimbursement models.
Excellent critical thinking, clinical judgment, and written communication skills.
Preferred Skills
Experience with denial analytics and reporting tools.
Knowledge of Medicare Advantage and Medicaid Managed Care regulations.
Why Join Us?
Work in a mission-driven environment focused on improving healthcare access and reimbursement.
Collaborate with a dynamic team of healthcare professionals and revenue cycle experts.
Competitive compensation and benefits package, including 401(k) with matching, health insurance, vision insurance, paid time off, paid lunches.
Job Details
Location: Plano, TX (Relocate before starting work – Required)
Shift: 8 hour shift
ERISA Recovery is an Equal Opportunity Employer
#J-18808-Ljbffr
Clinical Denials Specialist
with a strong background in
nursing (RN)
and a deep understanding of
medical necessity reviews
and
utilization management . In this role, you will work closely with internal case management teams, insurance providers, and clinical departments to analyze denied claims, prepare appeals, and ensure medical necessity documentation aligns with payer requirements.
About Us:
ERISA Recovery is a fast-growing company based in Dallas, TX, specializing in the recovery of aged and complex claims using the Federal ERISA appeals process. Our collaborative and innovative team offers an extraordinary opportunity for career growth in the ever-evolving revenue cycle industry.
Key Responsibilities
Review clinical documentation and denial letters to assess the reason for denial.
Conduct thorough
clinical reviews
for inpatient and outpatient cases.
Utilize
InterQual, MCG (Milliman), and McKesson review criteria
to determine medical necessity.
Draft and submit
clinical appeals
and
peer-to-peer reviews
as needed.
Collaborate with
ER case managers , physicians, and utilization review teams to gather and validate required documentation.
Evaluate and resolve issues related to
pre-certifications ,
authorizations , and
continued stay reviews .
Maintain up-to-date knowledge of payer policies, CMS guidelines, and industry standards.
Track denial trends and provide feedback for process improvement initiatives.
Qualifications
Registered Nurse (RN)
– active license required.
Minimum of
3-5 years
of clinical experience in inpatient and outpatient case management, including emergency room case management.
Strong experience with medical necessity criteria tools (InterQual, MCG/Milliman, McKesson Review) and pre-certifications, authorizations, and continued stay reviews.
Proven track record of
successful appeal writing
and overturning denials.
Familiarity with payer-specific guidelines and reimbursement models.
Excellent critical thinking, clinical judgment, and written communication skills.
Preferred Skills
Experience with denial analytics and reporting tools.
Knowledge of Medicare Advantage and Medicaid Managed Care regulations.
Why Join Us?
Work in a mission-driven environment focused on improving healthcare access and reimbursement.
Collaborate with a dynamic team of healthcare professionals and revenue cycle experts.
Competitive compensation and benefits package, including 401(k) with matching, health insurance, vision insurance, paid time off, paid lunches.
Job Details
Location: Plano, TX (Relocate before starting work – Required)
Shift: 8 hour shift
ERISA Recovery is an Equal Opportunity Employer
#J-18808-Ljbffr