Registered Nurse (RN) Lead, Post-Claims Denial Analyst

POSITION SUMARY Under the director of the CBO Director, the Lead RN Post-Claims Denial Analyst is responsible for Leading the post claim denial unit. Ensuring accurate clinical validation of medical necessity, optimizing reimbursement and reducing preventable denials. This role provides clinical expertise, oversees denial analysts, and collaborate with payers and internal teams to drive denial prevention strategies. KEY RESPONSIBILITIESLead and mentor denial analysts and nursing review staff; assign cases and monitor productivity. Develop and implement denial management strategies to improve overturn rates and reduce variances. Analyze denial trends and present findings to leadership. Perform clinical review of denied claims. Draft and oversee high quality denial appeal letters supported by clinical evidence and regulatory guidelines. Monitor payer policy changes (Medicare, Medicaid, Commercial plans) and adjust appeal strategies accordingly. Track appeal success rates, denial volumes, root causes and financial impact. Ensure accurate documentation in denial management system. QUALIFICATIONS AND EXPERIENCEActive unrestricted Registered Nurse license.Minimum 3-5 years of clinical experience (acute care, utilization review, case management, or similar role).3 years in denial management, utilization review or case management required. Strong knowledge of ICD-10, CPT, DRG structure, and medical necessity criteria (InterQual, MCG)Knowledge of CMS guidelines, Medicare Advantage, Medicaid, and commercial payer policies.Prior leadership or supervisory experience preferred.