Job Description

The role of the Denial Nurse is to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to denials.

The Denial Nurse will review for appropriate care and setting and following guidelines/policies as it relates to denials.

The Denial Nurse is responsible for processing denial letters for all affiliated groups, interpret denial language provided by the prior authorization nurse, coordinators, and medical directors, and place it into the appropriate templates while translating medical terminology into lay language and grading the reading level as appropriate.

Denial nurse will work closely with the coordinators in the department for clinical guidance on denial cases.

Qualifications

• Active California LVN License
• Minimum of 3+ year of prior authorization/ denials experience
• Minimum of 1+ year of acute care/case management experience
• Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
• Knowledge of computers, faxes, printers and all other equipment
• Ability to deal with responsibility with confidential matters
• Ability to work in a multi-task, high stress environment

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