RN Manager, Clinical Revenue Integrity and Appeals, Full Time - Days

Be a part of a world-class academic healthcare system, UChicago Medicine, as a RN Manager for the Revenue Cycle Department.

The Manager, Clinical Revenue Integrity & Appeals is responsible for providing operational leadership and oversight of a team of Registered Nurses dedicated to supporting clinical revenue integrity and reimbursement optimization across the health system. This role oversees nursing staff who partner with physicians, case management, utilization management, patient access, coding, revenue cycle, and payer organizations to prevent avoidable denials and maximize reimbursement through comprehensive clinical review, medical necessity validation, and evidence-based appeal development.

The Manager ensures timely, accurate, and compliant review of complex payer requests, third-party audits, prior authorization denials, and post-payment clinical denials. This leader develops standardized processes, monitors performance metrics, identifies denial trends, and collaborates across clinical and revenue cycle departments to improve documentation, reduce revenue risk, and enhance financial outcomes while maintaining compliance with regulatory and payer requirements.

This is a system-level leadership position responsible for establishing consistent practices across all hospitals and ambulatory entities within the organization.

Essential Functions

• Provides direct leadership, coaching, and performance management for a team of Registered Nurses responsible for clinical revenue integrity and payer appeal activities.
• Establishes standardized workflows, productivity expectations, quality standards, and service level agreements for assigned functions.
• Develops departmental goals, monitors key performance indicators, and implements process improvements to enhance operational effectiveness and reimbursement outcomes.
• Fosters collaboration between Revenue Cycle, Utilization Management, Patient Access, Case Management, Coding, Clinical Documentation Integrity, Compliance, and physician leadership.
• Recruits, develops, mentors, and retains a high-performing team while promoting professional development and continuous learning.
• Serves as a subject matter expert on payer medical necessity requirements and clinical denial prevention strategies.
• Oversees nursing review of commercial, governmental, and recovery audit requests to ensure accurate and timely clinical responses.
• Ensures clinical documentation supports billed services and coordinates with appropriate stakeholders to develop audit responses.
• Identifies recurring audit trends and collaborates with operational and physician leaders to implement corrective actions that reduce future audit exposure.
• Oversees clinical review of first-level denials for elective services requiring prior authorization.
• Ensures staff evaluate clinical documentation against payer medical policies and applicable coverage criteria.
• Directs the preparation of clinically sound reconsideration requests and appeals designed to obtain authorization prior to service whenever possible.
• Collaborates with Patient Access, Financial Clearance, Scheduling, and clinical departments to minimize avoidable authorization denials and treatment delays.
• Oversees development of comprehensive clinical appeals for post-service medical necessity denials utilizing evidence-based guidelines, payer policies, physician documentation, and nationally recognized clinical criteria.
• Ensures appeals are submitted accurately and within payer filing deadlines.
• Coordinates multidisciplinary efforts to maximize reimbursement for medically necessary services.
• Coordinates communication between nursing staff, physicians, advanced practice providers, and operational leaders when additional documentation is required to support medical necessity.
• Facilitates acquisition of supplemental clinical information necessary for peer-to-peer reviews, reconsiderations, and formal appeals.
• Partners with physician advisors and utilization management leaders to improve documentation practices and reduce preventable denials.
• Provides education to clinical departments regarding payer expectations, documentation opportunities, and denial prevention initiatives.
• Ensures all activities comply with organizational policies, payer contracts, CMS regulations, accreditation standards, and applicable federal and state requirements.
• Conducts quality reviews of clinical determinations, appeal letters, and audit responses to ensure consistency and effectiveness.
• Analyzes denial trends, appeal success rates, audit outcomes, turnaround times, and financial recovery opportunities.
• Develops action plans and collaborates with operational leaders to address root causes of recurring denials.
• Prepares executive reports and dashboards summarizing operational performance, financial impact, and improvement initiatives.

Required Qualifications

• Bachelor's degree in Nursing (BSN) required.
• Five (5) years of progressive clinical experience in acute care, utilization management, case management, revenue cycle, clinical appeals, or related healthcare operations.
• Demonstrated knowledge of medical necessity criteria, utilization review, payer authorization requirements, and clinical documentation standards.
• Experience with commercial and governmental payer appeals, clinical denials, and audit management.
• Current Registered Nurse (RN) license in good standing required.
• Certification in Case Management (CCM), Utilization Review (CPUR or equivalent), Revenue Cycle (CRCR, CRCE), or related professional certification preferred.

Skills

• Experience in an integrated health system or academic medical center.
• Knowledge of CMS regulations, InterQual®, MCG®, and payer medical policies.
• Strong understanding of medical necessity review, utilization management, payer reimbursement methodologies, and healthcare regulations.
• Demonstrated ability to interpret clinical documentation and apply evidence-based criteria to support reimbursement.
• Excellent analytical, problem-solving, and critical thinking skills.
• Exceptional written communication skills with experience developing persuasive clinical appeal narratives.
• Ability to build collaborative relationships with physicians, nursing leadership, operational leaders, and payer representatives.
• Strong project management, organizational, and process improvement capabilities.
• Proficiency with electronic health records, payer portals, utilization management systems, and revenue cycle applications.
• Ability to analyze data, identify trends, and translate findings into operational improvements.

Position Details

• Job Type/FTE: Full Time (1.0 FTE)
• Shift: Days, Monday-Friday
• Unit/Department: Revenue Cycle Integrity
• Work Location: Flexible Remote (Will need to commit to being onsite when needed)
• CBA Code: Non-union