Job Closed

This listing is no longer active.

Shriners Children's logo
Shriners Children's

Bringing hope and healing to families, every day.

Denials Management Appeals Nurse

Business AnalystBusiness AnalystFull TimeRemoteMid LevelTeam 10,001+Since 1922H1B No SponsorCompany SiteLinkedIn

Location

United States

Posted

45 days ago

Salary

0

Seniority

Mid Level

No structured requirement data.

Job Description

Denials Management Appeals Nurse

Shriners Children's

Role Description The Denials Management Appeals Nurse (Anesthesia) is responsible for managing our medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Denials Management Appeals Nurse (Anesthesia) will utilize their clinical background to address the clinical denials, as well as write sound, compelling factual arguments for appealing denials. The Denials Management Appeals Nurse (Anesthesia) is also responsible for maintaining a detailed knowledge of Third Party Payors and Governmental Payors clinical/medical necessity criteria, as well as filing compliant appeals in accordance with Third party and governmental contracts. - Performs a review of assigned cases comparing the bill to the medical record. - Performs a detailed comparison of charges to documentation to ensure services documented have been captured through the charge process. - Performs a detailed comparison of charges to documentation to ensure services not documented are not charged. - Reviews documentation to ensure that services typically performed with specific procedures are being documented so that charge capture may occur. - Review findings with the hospital representatives and obtains an agreement on the discrepancies. - Demonstrates tact and understanding in handling problems, has a good rapport with hospital and corporate staffs. - Follows up on appeals in a timely fashion to ensure that cases are completed. - Re-checks mathematical computations before finalizing letter and report. - Updates status of all cases assigned on minimum weekly basis. - Informs supervisor of any changes, problems, or concerns that arise at a facility. - In the event of a dispute with the requesting party’s audit findings, files an appeal with the third party or governmental payor. - Analyzes and interprets all medical necessity/clinical denials from third party payors or governmental payors. - Files appeals based on medical documentation and interpretation of medical necessity guidelines or InterQual criteria. This is not an all-inclusive list of this job’s responsibilities. The incumbent may be required to perform other related duties and participate in special projects as assigned. Qualifications - 5 years of clinical healthcare/hospital experience - 3 years of related Anesthesia experience - Third Party Payor Appeals/Revenue Cycle experience - Current RN license in State of employment - Working experience with Utilization Review activities and general knowledge of TJC, PRO, and other regulatory bodies. Requirements - Bachelor’s degree - BSN highly desired - Case Management certification - Experience reviewing hospital and professional claims, denials and EOB's, appealing claims and working on claims in an audit - Experience with Epic, Craneware, Waystar, software and applications Benefits - All employees are eligible for medical coverage on their first day. - Upon hire, all employees are eligible for a 403(b) and Roth 403(b) Retirement Saving Plan with matching contributions of up to 6% after one year of service. - Employees in a FT or PT status (40+ hours per pay period) will also be eligible for paid time off, life insurance, short term and long-term disability, and the Flexible Spending Account (FSA) plans and a Health Savings Account (HSA) if a High Deductible Health Plan (HDHP) is elected. - Additional benefits available to FT and PT employees include tuition reimbursement, home & auto, hospitalization, critical illness, pet insurance, and much more! - Coverage is available to employees and their qualified dependents in accordance with the plans. Benefits may vary based on state law.

Related Categories

Related Job Pages

More Business Analyst Jobs

HealthEdge logo

Senior Business Analyst

HealthEdge

Become a Digital Payer

Business Analyst45 days ago
Full TimeRemoteTeam 1,001-5,000Since 2005H1B Sponsor

• Leading business requirement conversations with customer and internal teams • Managing the end-to-end requirements involving all the stakeholders • Responsible for developing business and functional requirements for Claims, Enrollment, Provider, Authorization, Payment systems • Create solutions for current business processes using UST HealthProof’s core-admin ecosystem • Collaborate with business users, management, IT, and offshore staff • Contribute towards sprint planning, retrospective, go-live/no go-live evaluation meetings

United States
$120K - $140K / year
Full TimeRemoteTeam 11-50H1B No Sponsor

• Serve as the primary architect and SME for Metabase (our primary BI tool), developing and maintaining complex dashboards to track KPIs. • Analyze and interpret specialized healthcare data, with a heavy focus on clinical and financial healthcare reporting (e.g., claims data, denial rates, therapist utilization, and clinical outcomes). • Perform rigorous data validation to ensure data integrity and accuracy across all internal and external reporting. • Partner directly with multiple departments to create recurring dashboards that track company-wide progress toward strategic initiatives and financial KPIs. • Centralize data from multiple sources (CRM, HelpDesk, Task Management, Pendo) to build comprehensive performance dashboards for Customer Success and other service leadership teams. • Act as the technical Data SME during sales cycles for the Prompt BI platform, conducting high-level technical demos, identifying expansion opportunities, and partnering with Account Executives and CSMs to win deals. • Support enterprise, mid-market, and small-market clients by providing expert-level guidance, training, and tailored reporting solutions on the Prompt BI platform. • Build and maintain strong, consultative relationships with client leadership, translating their clinical and financial business needs into technical data solutions.

United States
$100K - $120K / year
Capco logo

Business Analyst - BCIM/TPM (She/He/They)

Capco

Capco, a Wipro company, is a management & technology consultancy dedicated to the financial services & energy industries

Business Analyst45 days ago
Full TimeRemoteTeam 1,001-5,000Since 1998H1B Sponsor

CAPCO POLAND Capco Poland is a global technology and management consultancy specializing in driving digital transformation across the financial services industry. We are passionate about helping our clients succeed in an ever-changing industry. We are also: • Experts in banking and payments, capital markets, and wealth & asset management • Committed to growing our business and hiring the best talent to help us get there • Focused on maintaining our nimble, agile, and entrepreneurial culture About the Role We are looking for a Business Analyst to join our Business Consulting team in Warsaw. This role will support transformation and governance-related initiatives, working closely with stakeholders across business and technology teams. The ideal candidate will bring strong Business Analysis and coordination skills, with experience supporting workshops, tracking actions, documenting outcomes, and driving collaboration across multiple stakeholders. Experience in BCIM (Business Continuity & Incident Management) or TPM (Third Party Management) is preferred but not essential. What You’ll Do • Support the planning, coordination, and facilitation of workshops and stakeholder sessions • Prepare meeting materials, capture outcomes, and track actions and dependencies • Document findings, recommendations, and business requirements in a structured and clear manner • Work closely with business and delivery teams to support transformation initiatives • Contribute to process improvement activities and workflow management discussions • Support governance and programme reporting activities where required What We’re Looking For • Proven experience in a Business Analyst or project coordination role • Strong stakeholder management and communication skills • Experience facilitating workshops and documenting outcomes/actions • Ability to manage multiple workstreams and priorities effectively • Strong documentation and organisational skills • Experience with workflow management or process design is advantageous Nice to Have • Exposure to BCIM, operational resilience, or Third Party Management initiatives • Experience within financial services, consulting, or regulated environments • Familiarity with governance, controls, or transformation programmes • Understanding of Agile delivery methodologies WHY JOIN CAPCO? • Employment contract and/or Business to Business – whichever you prefer • Speaking English on a daily basis, mainly in contact with foreign stakeholders and peers • Ongoing learning opportunities to help you acquire new skills or deepen existing expertise • Being part of the core squad focused on the growth of the Polish business unit • A flat, non-hierarchical structure with direct exposure to senior stakeholders and clients • A work culture focused on innovation and creating lasting value for clients and employees ONLINE RECRUITMENT PROCESS STEPS • Screening call with the Recruiter • Competencies interview with Capco Hiring Manager • Client interview • Feedback / Offer Follow us here or contact us directly: recruiting.poland@capco.com #LI-Hybrid

Poland
Dev Technology logo

QA Tester/Business Analyst

Dev Technology

Dev Technology is a growing IT company with an employee-centric culture that works on mission-critical projects for the federal government. We partner with our federal customers to deliver technology services and solutions, and to drive our client’s missions forward through innovation. We use Agile and DevSecOps principles to provide services including application development, biometrics and identity management, cloud and infrastructure optimization, IT and legacy modernization, and data management.

Business Analyst45 days ago
Full TimeRemoteTeam 201-500

Role Description Dev Technology Group is seeking a Software Quality Assurance (QA) Engineer / Tester to ensure the quality, reliability, and compliance of Microsoft Teams applications and Power Platform solutions within a large federal environment. This role supports quality assurance activities across multiple delivery teams, validating Teams-based applications (apps, bots, integrations) and Power Platform solutions (Power Apps, Power Automate, Power BI) throughout the software development lifecycle. The QA Engineer / Tester works closely with developers, Scrum Masters, and stakeholders to ensure solutions meet functional requirements, performance expectations, and compliance standards aligned with mission objectives. This position supports structured, mission-driven delivery environments and focuses on maintaining quality, consistency, and reliability across multiple workstreams. Key Responsibilities - This role is 60% manual testing and 40% business analysis. - Test Microsoft Teams applications, including custom apps, bots, tabs, and integrations, to ensure functionality, performance, and reliability. - Validate Power Platform solutions, including: - Power Apps (Canvas and Model-Driven) - Power Automate workflows and approvals - Power BI reports and dashboards (as applicable) - Test end-to-end user scenarios across Teams and Microsoft 365 services, ensuring seamless integration and user experience. - Validate data handling, storage, and integrations to ensure accuracy, completeness, and compliance. - Document defects and track issues through resolution in collaboration with development teams using tools such as Azure DevOps or Jira. - Support regression testing cycles to ensure stability across releases, updates, and platform changes. - Assist with the development and execution of test plans, test cases, and validation procedures for Teams and Power Platform solutions. - Collaborate with developers and Scrum teams to ensure alignment with requirements, user stories, and acceptance criteria. - Participate in release readiness, UAT support, and production validation activities. - Ensure testing aligns with security, compliance, and governance standards within a regulated environment. Qualifications - A Bachelor's with a minimum of 3 years of related experience in a government contract M365 environment. - Experience testing enterprise applications, integrations, or cloud-based solutions. - Strong understanding of software testing methodologies. - Experience testing or supporting Microsoft Teams applications and/or Power Platform solutions. - Experience documenting defects and supporting resolution workflows. - Experience supporting QA activities in Agile, Scrum, or DevOps environments. - Strong analytical, problem-solving, and communication skills. - Ability to collaborate effectively within cross-functional technical teams. Preferred Qualifications - Experience as both a Tester and a Business Analyst. - Experience supporting federal or highly regulated environments (e.g., M365 GCC). - Familiarity with Microsoft Teams development patterns (apps, bots, Graph API integrations). - Experience testing Power Platform solutions (Power Apps, Power Automate, Power BI). - Experience validating workflows, automations, and system integrations. - Knowledge of QA tools or test management platforms (e.g., Azure DevOps, Jira). Benefits - Generous and flexible time-off policy. - Flexible work schedules and telework options, including remote work availability for eligible projects. - Career development opportunities including a mentorship program, technical and management training through Dev University, hands-on learning through DevLab, tuition reimbursement, and paid training opportunities. - Industry-leading benefits including a choice of two health plans that include dental and vision, flexible spending account, commuter benefits, life insurance, and more. - 401K matching with a 5% matching contribution. - Regular team and company social events including our annual party, happy hours, fitness challenges, and more. - A focus on community engagement including company-wide support activities, employer match for donations, and time off for volunteer efforts. Salary Information Our estimated salary range for this position is $62,400 - $115,000. This presented salary range is not a guarantee of compensation or salary. Offered salary is based on experience, geographic location, and possibly contractual requirements as appropriate to the role. *Salary could fall outside of this range.

United States
$62.4K - $115K / year
Job Closed