St. Luke's University Health Network

Compensation

Full Description

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. The Denials Management Specialist reviews inpatient CMS and third party denials for medical necessity and tracks outcomes regarding appeal process. Assists billing staff regarding outpatient denials for experimental, coding or other issues that may require record review. Provides billing with information needed to obtain payment of claims. JOB DUTIES AND RESPONSIBILITIES: Reviews all Inpatient Retroactive Denials in the Denials Management Work Queues for Medical Necessity and Late-Pick-Up/Notification that are entered by Case Management and Business Office. Monitors retro denials to ensure resolution within required time frames and logging of action e.g. no appeal, appeal level and final decision with revenue impact. Assists Case Management as necessary to ensure that documentation is entered and transmitted to insurance carriers within acceptable timeframes to comply with appeal deadlines. Provides feedback to Case Management that can help in preventing future denials and assists in maintaining good communication and process flow between the 2 departments. Responsible for writing appeal letters for Inpatient CMS and Commercial late pick-ups, medical necessity, and other requested denials as deemed clinically appropriate. Investigates managed care and commercial insurance rejections, denials for possible experimental services and coding issues, providing supplemental information to resolve claim. Identifies operational issues that contribute to denials and rejections. Works with departments and providers to implement corrective actions to minimize lost revenue due to denials and rejections. Assists in preparing reports regarding denials to include volumes, number of appeals, case resolution, and impact on revenue and trending. Coordinates RAC appeals for complex case reviews for medical necessity, including determining if appeal is appropriate and communicating with vendor to ensure timely filing of same. Performs writing of RAC/MAC appeals at appropriate levels and documenting status. PHYSICAL AND SENSORY REQUIREMENTS: Requires sitting for up to 4 hours per day, 2 hours at a time. Standing for up to 4 hours per day, 3 hours at a time. Requires occasional fingering, handling and twisting and turning. Occasionally requires reaching above shoulder level. Must have the ability to hear as it relates to normal conversation, seeing as it relates to general, peripheral and near vision, visual monotony. EDUCATION: Graduate of an accredited professional nursing program. Registered nurse with current license to practice in the state of Pennsylvania or seek Pennsylvania licensure through reciprocity. Advanced degree preferred. TRAINING AND EXPERIENCE: Minimum of 2-5 years of clinical nursing experience in an acute care hospital setting required. Prefer minimum of 2-5 years’ experience in case management and/or utilization management required. Prefer financial experience related to appeal processes with insurance providers. Demonstrated experience relating to all types of payers/providers. Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!! St. Luke's University Health Network is an Equal Opportunity Employer. Founded in 1872, St. Luke’s University Health Network (SLUHN) is a fully integrated, regional, non-profit network of more than 23,000 employees providing services at 16 campuses and 350+ outpatient sites. With annual net revenue in excess of $4 billion, the Network’s service area includes 11 counties in two states: Lehigh, Northampton, Berks, Bucks, Carbon, Montgomery, Monroe, Schuylkill and Luzerne counties in Pennsylvania and Warren and Hunterdon counties in New Jersey. St. Luke’s hospitals operate the largest network of trauma centers in Pennsylvania, with the Bethlehem Campus being home to St. Luke’s Children’s Hospital. SLUHN is the only Lehigh Valley-based health care system to earn Medicare’s five-star ratings (the highest) for quality, efficiency and patient satisfaction. It is both a Leapfrog Group and Healthgrades Top Hospital and a Newsweek World’s Best Hospital. The Network’s flagship University Hospital has earned the 100 Top Major Teaching Hospital designation from Premier 13 times total and eleven years in a row, including in 2023 when it was identified as THE #4 TEACHING HOSPITAL IN THE COUNTRY. In 2021, St. Luke’s was identified as one of the 15 Top Health Systems nationally. St. Luke’s is the ONLY health care institution in the Lehigh Valley to be named a Top Workplace regionally repeating the exclusive honor for the third year in a row. Also, for the third straight year, St. Luke’s has been a Top Workplaces in the Philadelphia Region by the Philadelphia Inquirer, ranking 9th in the large employer category for 2025 and the only health care system in PA to receive this award. In 2025, St. Luke’s was recognized as a national Top Workplaces by USA Today, three years in a row, including the 3rd best health care system in the nation in 2023 and 2024. Lastly, in 2025, St. Luke’s was named a Top Workplace in New Jersey for the third year in a row. Learn More Here.