🩺 Registered Nurse – Clinical Appeals & Denials Specialist (Remote)
Job ID: 00065772435
Category: Business Processes
Location: Hatboro, United States
Employment Type: Full-time
Work Model: Work from Home
Date Published: October 8, 2025
Schedule: Monday to Friday – Eastern Time
About the Role
As a Registered Nurse (RN) at Cognizant, you will play a vital role in clinical denial management, ensuring accurate review and resolution of medical necessity denials from healthcare providers to payers. You’ll analyze and process clinical denials, ensuring compliance with Medicare, Medicaid, and third-party payer guidelines.
You will collaborate closely with stakeholders, applying clinical expertise and critical thinking to achieve optimal outcomes in appeals and denial management.
Key Responsibilities
Maintain ownership and responsibility for assigned accounts.
Review and analyze clinical denials (e.g., preauthorization, medical necessity, non-covered services, investigational/experimental cases).
Draft and submit medical necessity determinations based on Medicare, Medicaid, and other payer guidelines.
Utilize InterQual, Milliman Clinical Guidelines (MCG), and insurer-specific criteria for medical necessity reviews.
Perform retro-authorization reviews as per payer requirements.
Identify denial patterns to mitigate risks and reduce regulatory penalties.
Escalate potential risks to leadership or client partners.
Maintain detailed documentation and tracking of claims/appeals in relevant systems.
Apply critical thinking and interpret policies to ensure accurate clinical determinations.
Required Qualifications
Registered Nurse (RN) licensure.
2–3 years combined experience in clinical practice and/or utilization management within managed care.
3 years experience in healthcare revenue cycle or clinic operations.
Proficiency in Clinical Appeals, Grievances, Precertification, and Utilization Reviews.
Intermediate proficiency with Microsoft Office (Excel, Word, Outlook).
Experience with inpatient and outpatient settings.
Preferred Qualifications
Epic system experience.
Experience drafting appeals disputing inpatient clinical validation audits.
Compensation & Benefits
💰 Salary Range: USD $70,000 – $74,000/year (based on experience and qualifications)
🎯 Incentives: Eligible for annual performance-based bonuses and stock awards.
Comprehensive Benefits Package Includes:
Medical, Dental, Vision, and Life Insurance
Paid Holidays + Paid Time Off
401(k) Plan with Company Contributions
Long-term & Short-term Disability
Paid Parental Leave
Employee Stock Purchase Plan
📅 Applications Accepted Until: October 20, 2025
Work Arrangement
Fully Remote within the United States
Flexible working environment supporting work-life balance
Occasional virtual or in-person interviews may be required
About Cognizant
Cognizant is one of the world’s leading professional services firms, transforming business, operating, and technology models for the digital era.
🌍 Over 300,000 associates globally
🏆 Featured in Forbes World’s Best Employers 2024
💡 Focused on innovation, inclusion, and ethical excellence
Learn more: www.cognizant.com
Equal Opportunity Statement
Cognizant is an Equal Opportunity Employer. All qualified applicants will be considered without regard to race, color, sex, religion, creed, sexual orientation, gender identity, national origin, disability, genetic information, pregnancy, veteran status, or any other protected status.
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