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Perm Staff Jobs is seeking a Registered Nurse (RN) Case Manager, Utilization Review for a nursing job in Tariffville, Connecticut.

• Specialty: Utilization Review
• Discipline: RN
• Duration: Ongoing
• Employment Type: Staff

Location Detail: 9 Farm Springs Rd Farmington (10566)

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Position Summary:

The level 2 Denial Specialist Appeal Writer reviews and analyzes Diagnostic Related Grouper (DRG) downgrades, preparing detailed, evidence-based appeal letters to defend assigned DRGs and optimize reimbursement. This role requires interpreting medical records, applying official coding guidelines, reviewing payer contracts and exercising clinical judgment. The specialist also helps prevent future downgrades by identifying trends and providing feedback to enhance coding accuracy and clinical documentation. Provide ongoing education to HHC Institute leaders, providers, coding and CDI teams on DRG validation, documentation best practices, payer guidelines and best practices to minimize future denials.

Position Responsibilities:

Key Areas of Responsibility

·       Provide ongoing education to HHC Institute leaders, providers, coding and CDI teams on DRG validation, documentation best practices, payer guidelines and best practices to minimize future denials.

·       Review payer DRG downgrade denials to assess validity and potential for appeal.

·       Analyze medical records, coding and clinical documentation to support the billed DRG using ICD-10-CM/PCS guidelines, UHDDS definitions, Coding Clinic, and regulatory requirements.

·       Prepare and submit persuasive appeal letters that include a patient summary, evidence-based criteria, coding references and citations from authoritative sources.

·       Maintain accurate appeal records in designated systems, track statuses and meet payer-specific submission deadlines.

·       Lead trend analysis to identify denial patterns and recommend process improvements.

·       Achieve departmental KPIs related to turnaround times, appeal success rates and denial reduction targets.

Education

·       Provide ongoing education to HHC Institute leaders, providers, coding and CDI teams on DRG validation, documentation best practices, payer guidelines and best practices to minimize future denials.

·       Collaborates with CDI provider leads at each facility to enhance denial proof documentation.

·       Stay current with payer policies, regulatory changes, coding guidelines and industry best practices to support revenue protection efforts.

Communication

·       Collaborate with Coding, CDI and physicians to clarify documentation and ensure accurate DRG assignment.

·       Serve as primary contact with payers for DRG-related denials, clearly communicating clinical and coding rationale.

·       Provide timely updates and feedback to leadership and departments on denial prevention efforts and appeal outcomes.

Other

·       Performs other related duties as required.

·       Mentors new and existing team members.

·       Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.

Working Relationships:

This Job Reports To:  Medical Director

Requirements and Specifications:

Education

Minimum: Bachelor of Science in Nursing

·       Preferred: Master’s degree or equivalent

Experience

·       Minimum: Four (4) years of progressive on-the-job inpatient and/or clinical documentation experience within healthcare revenue cycle or other healthcare field.

·       Preferred: Six (6) years of progressive on-the-job experience with DRG denial management and appeals preferred.

Licensure, Certification, Registration

·       Active Registered Nurse license from the State of Connecticut

·       Certified Clinical Documentation Specialist (CCDS), Certified Documentation Integrity Practitioner (CDIP)

Language Skills

·       Strong written and verbal communication skills. 

Knowledge, Skills and Ability Requirements:

·       Strong knowledge of ICD-10-CM/PCS coding, DRG assignment and MS-DRG/APR-DRG systems.

·       Excellent written communication skills, with the ability to translate complex clinical and coding concepts into persuasive arguments.

·       Proficient with tracking systems, data management tools, and payer contract requirements, including appeal timelines and regulations.

·       Attention to detail, analytical thinking and the ability to meet deadlines in a fast-paced environment.

·       Strong organizational, interpersonal, communication and collaboration skills.

·       Experienced in cross-functional teamwork to research and resolve issues using innovative solutions.

·       Strong problem-solving and critical thinking abilities; able to work independently while delivering outstanding customer service.

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With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth. Here, you are part of an organization on the cutting edge – helping to bring new technologies, breakthrough treatments and community education to countless men, women and children. We know that a thriving organization starts with thriving employees-- we provide a competitive benefits program designed to ensure work/life balance. Every moment matters. And this is your moment.