Manager Clinical Denials - FT - Day - Revenue Integrity & Denials Mgmt Lawrenceville NJ

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range:

$94,140.80 - $122,990.40

Scheduled Weekly Hours:

40

Position Overview

The Manager, Clinical Denials is responsible for the oversight and management of inpatient and outpatient clinical denial activities, including medical necessity denials, patient status determinations, readmissions, and DRG downgrades. This role ensures timely, compliant, and effective clinical appeal processes while driving denial prevention through root-cause analysis, education, and collaboration with clinical and operational stakeholders.

MINIMUM REQUIREMENTS

• Education: Bachelor’s degree required. Clinical background is strongly preferred.
• Experience: · Minimum of five (5) years of progressive experience in hospital clinical denials, utilization review, appeals, CDI, or related revenue cycle functions · Prior leadership or supervisory experience required
• Other Credentials: Registered Nurse (RN) preferred
• Knowledge and Skills: · Strong understanding of inpatient and outpatient medical necessity, patient status rules, and payer clinical policies · Working knowledge of DRG validation and downgrade methodologies (payer and third-party audit firms) · Ability to translate clinical concepts into operational workflows and appeal strategies · Strong written communication skills, including clinical appeal writing and documentation standards · Analytical mindset with experience using denial trends to drive prevention
• Special Training: Proficient in Microsoft Office. Working knowledge of insurance contracting principles and payer administrative policies.
• Mental, Behavioral and Emotional Abilities: Ability to provide leadership and definition to a new team. Must be skilled in management to provide guidance as priorities change. Must have ability to meet deadlines and attention to detail. Must demonstrate good judgment. Must be metric-driven and results oriented.
• Usual Work Day: 8 Hours
• Reporting Relationships
• Reports to: Director, Denials Management & Revenue Integrity
• Supervises: Clinical Appeals RN(s), DRG Downgrade CDI RN(s), DRG Downgrade Denial
• Specialist(s), Inpatient and Outpatient Clinical Denial Specialist(s)

ESSENTIAL FUNCTIONS

• Oversees daily operations of the clinical denials function, ensuring appropriate prioritization, workflow adherence, and inventory control
• Establishes and maintains standardized clinical denial and appeal workflows for inpatient and outpatient denials
• Provides leadership and guidance on clinical appeal strategy
• Oversees DRG downgrade review and defense processes in partnership with CDI and clinical leadership
• Ensures clinical appeals are complete, timely, and compliant with payer and regulatory requirements
• Reviews denial trends and root causes, translating findings into targeted education and prevention initiatives
• Partners with Utilization Review, Case Management, CDI, Medical Staff, Managed Care, and Compliance to reduce avoidable denials
• Monitors team productivity, quality, and outcomes; provides coaching and performance feedback
• Maintains current knowledge of payer policies, regulatory requirements, and industry best practices
• Supports audit readiness and responses to payer or external review entities
• Performs other duties as assigned

PHYSICAL DEMANDS AND WORK ENVIRONMENT

• Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.
• Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing
• Anticipated Occupational Exposure Risks Include the following: N/A

This position is eligible for the following benefits:

• Medical Plan

• Prescription drug coverage & In-House Employee Pharmacy

• Dental Plan

• Vision Plan

• Flexible Spending Account (FSA)

- Healthcare FSA

- Dependent Care FSA

• Retirement Savings and Investment Plan

• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance

• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance

• Disability Benefits – Long Term Disability (LTD)

• Disability Benefits – Short Term Disability (STD)

• Employee Assistance Program

• Commuter Transit

• Commuter Parking

• Supplemental Life Insurance

- Voluntary Life Spouse

- Voluntary Life Employee

- Voluntary Life Child

• Voluntary Legal Services

• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance

• Voluntary Identity Theft Insurance

• Voluntary Pet Insurance

• Paid Time-Off Program

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. 

The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.