Northwell Health · 1 day ago
Clinical Denials & Appeals Specialist
United States
Full-time
Remote
Mid Level
$78K/yr - $130K/yr
4+ years expNorthwell Health is a leading healthcare provider, and they are seeking a Clinical Denials & Appeals Specialist. The role involves reviewing denial trends, serving as a resource for Corporate Compliance Audits, and collaborating with various stakeholders to ensure appropriate care and compliance with regulations.
ConsultingHealth CareHealth DiagnosticsMedicalPublishing
Responsibilities
Serves as liaison between the patient and facility/physician and the third party payer
Prepares and defends level of care and medical necessity for assigned case
Collaborates with physician advisor, payor representative and site case managers to facilitate appropriate level of care decisions and billing status and ensures compliance with the Utilization Review standard and regulations
Performs concurrent and retrospective utilization management using evidenced-based medical necessity criteria; conducts clinical reviews and formulates appeal letters to support appropriateness of admission and continued length of stay
Ensures compliance with current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately reflect patient’s severity of illness and intensity of services provided
Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions
Qualification
Required
Graduate from an accredited School of Nursing
Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed
Must have experience with Milliman Care Guidelines and/or InterQual
Preferred
Bachelor's Degree in Nursing, preferred
Must be enrolled in an accredited BSN program within two (2) years and obtain a BSN Degree within five (5) years of job entry date
Inpatient clinical experience; 4+ years preferred
Prior Acute Case Management and/or Utilization Review experience, preferred
Company
Northwell Health
Northwell Health is New York State’s largest health care provider and private employer, with 28 hospitals, about 1,000+ outpatient facilities and more than 16,000 affiliated physicians.
10001+ employees
H1B Sponsorship
Northwell Health has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2021 (18)
2020 (13)
Funding
Current Stage
Late StageTotal Funding
$58.3MKey Investors
National Institute of Mental HealthNational Human Genome Research InstituteBreakthrough Discoveries
2025-12-02Grant· $4M
2025-10-23Grant· $3.2M
2025-06-16Grant· $2.3M
Leadership Team
Michael Dowling
President and CEO
Nick Stefanizzi
Chief Executive Officer at Northwell Direct
Recent News
Morningstar.com
2025-12-15
Company data provided by crunchbase