Clinical Payer Integrity Nurse
- Experience
- Mid
- Employment
- Full-time
Open to US only. Set where you work from to check your eligibility.
No BS summary
Remote role for a registered nurse with 2–3 years clinical review/payer integrity or utilization management experience. Must hold active RN licensure. Full-time, US-based (KY/Ashland) role supporting denial review, appeals, and clinical documentation for reimbursement.
Core skills
Required skills
Clinical Payer Integrity Nurse Remote-KY At UK King's Daughters, we’re not just a healthcare facility — we’re a family of dedicated professionals who share a passion for making a meaningful difference in the lives of our patients. We’re more than just a place to work; we’re a place to grow, thrive, and contribute to our community. Job Description : Job Summary Responsible for ensuring accurate reimbursement by resolving denied claims through effective appeals processes. Reviews and analyzes denials to identify root causes and opportunities for successful resolution. Collaborates with clinical and billing teams to gather documentation and support appeals. Develops strategies to retain appropriate reimbursement and monitors outcomes to improve future processes. Coordinates with providers, coding, billing, and payer representatives to enhance claims and reimbursement effectiveness. Essential Functions • Conducts clinical reviews of claims and documentation to ensure compliance with payer policies, medical necessity, and clinical standards of care. • Analyzes denial trends related to clinical care, identifies root causes, and develops strategies for resolution and prevention. • Researches patient records and clinical documentation to gather information supporting appeals. • Reports and records denials using designated systems and ensures that the clinical documentation supports the services billed. • Reviews and interprets third-party contract language and payment models. • Analyzes hospital claims for accurate charges and documentation. • Completes and processes appeals within required timeframes and deadlines while referencing guidelines and standards of care. • Assists internal and external customers with denials, appeals, and payment inquiries. • Communicates daily with clinical departments, revenue cycle teams, and payers to facilitate resolution of clinical billing disputes.. • Performs other duties as assigned. Education Requirement Bachelor’s degree in nursing, healthcare administration, or a related field Master’s degree in nursing, healthcare administration, or a related field is preferred Experience Requirement 2-3 years of experience in clinical review, payer integrity, utilization management, or a relevant area An equivalent combination of education and experience may be considered. All experience must be paid and in the same related field. Part-time and PRN experience will be prorated based on hours worked per week. Volunteer work and internships for academic credit are not counted. Certifications & Licensures Maintains active RN licensure Working Conditions A. Lifting, pushing, and/or pulling objects up to 50lbs: 2. Occasional ( B. Lifting, pushing, and/or pulling objects over 50lbs: 1. Never C. Standing or walking with objects up to 10lbs: 3. Intermittent (10% - 50% of the time) D. Standing or walking with objects up to 25lbs: 2. Occasional ( E. Sitting at computer workstation for extended periods: 4. Regular (> 50% of the time) F. Risk of back injury from moving, lifting or positioning patients, equipment, or materials: 1. Never G. Repetitive motion: 4. Regular (> 50% of the time) H. Working at heights above 4 feet: 1. Never I. Working in confined spaces: 1. Never J. Risk of injuries from use of equipment on the job: 1. Never K. Job-related travel: 2. Occasional ( L. Loud noises: 1. Never M. Temperature extremes: 1. Never N. Hazardous chemicals and fumes including waste: 1. Never O. Radiation: 1. Never P. Burns: 1. Never Q. Cuts/Punctures: 1. Never R. Bloodborne/airborne pathogens: 1. Never S. Recombinant DNA or viral vectors: 1. Never T. Combative/violent people: 1. Never U. Animal handling (including carcasses): 1. Never V. Please specify other(s) and amount of exposure (i.e. Occasional, Intermittent or Regular): N/A Physical Demands This position requires intermittent sitting at a computer workstation for extended periods of time; performing tasks with repetitive motions (such as typing); intermittent standing or walking with objects weighing up to 10 pounds; occasional standing or walking with objects up to 25 pounds; and occasional lifting, pushing, and/or pulling objects weighing up to 50 pounds. Department : Payer Integrity Shift : Days (United States of America) Time Type : Full time Address : 2201 Lexington Ave City, State : Ashland, Kentucky Posted: 2026-07-20T00:00:00.000Z
What you'll do
- Conducts clinical reviews of claims and documentation to ensure compliance with payer policies, medical necessity, and clinical standards of care.
- Analyzes denial trends related to clinical care, identifies root causes, and develops strategies for resolution and prevention.
- Researches patient records and clinical documentation to gather information supporting appeals.
- Reports and records denials using designated systems and ensures that the clinical documentation supports the services billed.
- Reviews and interprets third-party contract language and payment models.
- Analyzes hospital claims for accurate charges and documentation.
- Completes and processes appeals within required timeframes and deadlines while referencing guidelines and standards of care.
- Assists internal and external customers with denials, appeals, and payment inquiries.
- Communicates daily with clinical departments, revenue cycle teams, and payers to facilitate resolution of clinical billing disputes.
- Performs other duties as assigned.
What they require
- Bachelor’s degree in nursing, healthcare administration, or a related field (Master’s preferred).
- 2-3 years of experience in clinical review, payer integrity, utilization management, or a relevant area. An equivalent combination of education and experience may be considered. All experience must be paid and in the same related field. Part-time and PRN experience will be prorated. Volunteer work and internships for academic credit are not counted.
- Maintains active RN licensure.
A healthcare facility and family of dedicated professionals focused on making a meaningful difference in the lives of patients and the community.