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#97735 (RN) Clinical Appeals Nurse Specialist

Filing Deadline: Mon 2/25/2019

UCSD Layoff from Career Appointment: Apply by 02/13/2019 for consideration with preference for rehire. All layoff applicants should contact their Employment Advisor.

Special Selection Applicants: Apply by 02/25/2019. Eligible Special Selection clients should contact their Disability Counselor for assistance.


UC San Diego Health is a Magnet designated organization, which is prestigious recognition that applies to only 6% of all U.S. hospitals. Magnet is the “gold standard” for nursing excellence and is based on strengths in five key areas which include transformational leadership, structural empowerment, exemplary professional practice, new knowledge, innovation and improvements and empirical quality results. UC San Diego Health has held its Magnet status since 2011.

The Clinical Appeals Nurse Specialist will coordinate, manage and resolve/overturn clinical related reimbursement denials on behalf of the Hospital Billing Patient Financial Services department. This person will be required to review patient medical records utilizing clinical and regulatory knowledge/skills as well as knowledge of payer requirements to determine why accounts have been denied and whether an appeal is required. This person will be expected to utilize pre-existing criteria, other resources and clinical evidence to develop sound and well-supported appeal arguments. They will be expected to prepare convincing appeal arguments using pre-existing criteria sets and/or clinical evidence from existing libraries of clinical references and/or regulatory arguments. This person may have responsibility to participate in Administrative Law Judge hearings by providing testimony, as necessary; as such, this person will be expected to be an expert with searching for and providing the appropriate supporting clinical evidence to support sound arguments.

While not required, a cover letter is highly recommended when applying to this position.


  • Must be a graduate from an accredited school of nursing.
  • RN License issued by the State of California.
  • Must have a minimum of three to five (3-5) years of active nursing experience.
  • Prior case management and clinical denials management experience.
  • Experience with McKesson (interQual) and/or Milliman Care Guidelines.
  • Proficient knowledge of Microsoft Outlook and Word.
  • Exceptional organizational and work flow management skills and ability to multi-task and work independently with minimal supervision.


  • Certification in Case Management (CCM)
  • Professional Utilization Review (PUR)
  • Knowledge of government reimbursement methodologies and denial issues.
  • Government payor knowledge, commercial payor knowledge and contract interpretation skills.


  • Must be able to work various hours and locations based on business needs.
  • Selected candidate may be hired at the CNIII level pending review and approval by the Nurse Executive Council.
  • Employment is subject to a criminal background check and pre-employment physical.

UC San Diego Health is the only academic health system in the San Diego region, providing leading-edge care in patient care, biomedical research, education, and community service. Our facilities include two university hospitals, a National Cancer Institute-designated Comprehensive Cancer Center, Shiley Eye Institute, Sulpizio Cardiovascular Center, and several outpatient clinics. UC San Diego Medical Center in Hillcrest is a designated Level I Trauma Center and has the only Burn Center in the county. We invite you to join our dynamic team!

Applications/Resumes are accepted for current job openings only. For full consideration on any job, applications must be received prior to the initial closing date. If a job has an extended deadline, applications/resumes will be considered during the extension period; however, a job may be filled before the extended date is reached.

UC San Diego Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity or sexual orientation. For the complete University of California nondiscrimination and affirmative action policy see: http://www-hr.ucsd.edu/saa/nondiscr.html

UC San Diego is a smoke and tobacco free environment. Please visit smokefree.ucsd.edu for more information.

UC San Diego Health Sys
Payroll Title:
Medical Center Business Office
Salary Range
Commensurate with Experience
Greenwich Drive
Appointment Type:
Appointment Percent:
NX Contract
Total Openings:
Work Schedule:
Days, 8 hrs/day, M-F


As a federally-funded institution, UC San Diego Health maintains a marijuana and drug free campus. New employees are subject to drug screening.