Clinical Denials Management Specialist

Job description

**This position is listed on behalf of a partner company, which manages all applications and next steps. Our partner is looking for a Clinical Denials Management Specialist based in the United States.** In this fully remote role, you will leverage your clinical expertise and analytical skills to review, investigate, and appeal denied hospital insurance claims across a healthcare system. You will analyze clinical documentation, billing records, payer policies, and patient histories to develop compelling, evidence-based appeals that support appropriate reimbursement. Working closely with nursing, utilization management, revenue integrity, and patient financial services teams, you will help resolve complex denials and identify opportunities to prevent future claim rejections. You will address a broad range of clinical and financial issues, including medical necessity, level-of-care determinations, clinical validation, and charge discrepancies. Your work will directly contribute to revenue integrity, regulatory compliance, and the financial sustainability of healthcare services. This opportunity is ideal for an experienced registered nurse with strong clinical judgment, excellent writing skills, and a passion for improving healthcare reimbursement processes. ### Accountabilities - **Review and appeal clinical denials:** Investigate denied hospital claims across clinical services, determine the most appropriate response, and develop comprehensive appeals or alternative resolution strategies based on the available evidence. - **Conduct detailed account research:** Review patient encounter histories, electronic medical records, payer portals, billing documentation, charge histories, payment records, and other information systems to establish the facts needed for each case. - **Develop individualized appeal letters:** Prepare clear, persuasive, and well-supported written appeals that reflect each patient's severity of illness, intensity of services, clinical circumstances, denial category, and supporting documentation. - **Defend clinical necessity and validity:** Evaluate and challenge denials involving medical necessity, clinical validation, inpatient versus observation status, neonatal intensive care unit (NICU) level of care, readmissions, and services classified as experimental or inconsistent with payer policies. - **Address billing and charge-related denials:** Investigate charge capture and charge audit issues, identify discrepancies, make appropriate charge corrections, and support accurate rebilling when required. - **Apply coding and reimbursement standards:** Interpret CPT and HCPCS codes, ICD classifications, UB-04 revenue codes, modifiers, billing guidelines, and relevant government and commercial payer regulations to support appropriate reimbursement. - **Collaborate with cross-functional teams:** Partner with pre-access, patient financial services, revenue integrity, utilization management, and clinical departments to obtain additional records, clarify clinical details, and strengthen appeal submissions. - **Apply utilization review criteria:** Evaluate inpatient and observation classifications using established clinical review frameworks, including MCG and InterQual, and incorporate relevant findings into denial defense strategies. - **Identify root causes and prevent future denials:** Investigate recurring denial patterns, collect supporting evidence, adjust accounts when appropriate, and recommend corrective actions to improve documentation, billing accuracy, and reimbursement outcomes. - **Provide education and reporting:** Prepare reports on clinical denial trends, share findings with leadership, and deliver education or training on payer requirements, documentation practices, and effective denial prevention strategies. - **Interpret payer policies and contracts:** Review payer guidelines and contractual language to determine applicable requirements and develop appropriate responses to disputed claims. - **Maintain accurate account records:** Use multiple clinical and financial technology systems to gather, validate, and document information supporting appeals and account adjustments. - **Manage competing priorities independently:** Work efficiently in a high-volume environment, adapt to changing reimbursement requirements, reprioritize assignments as needed, and meet established productivity and quality expectations. - **Maintain effective remote collaboration:** Use Microsoft Teams and other communication tools to coordinate with stakeholders, participate in virtual meetings, and maintain consistent communication while working remotely. ## Requirements - **Education:** A bachelor's degree in nursing, management, business, or a related field is required. Candidates whose bachelor's degree is in a non-nursing field must also hold at least an associate degree in nursing. A master's degree or other advanced degree is preferred. - **Professional nursing experience:** Active Registered Nurse (RN) licensure is required, along with at least three years of experience as a registered nurse in an acute clinical setting. - **Clinical experience or appeals expertise:** At least one year of experience in an intensive care unit (ICU) or medical-surgical unit is required, or at least one year of demonstrated proficiency in writing appeals for hospital services. - **Utilization review experience:** At least two years of utilization review or utilization management experience using InterQual and/or MCG criteria is required, or at least two years of appeals experience involving these clinical review frameworks. - **Clinical coding and billing knowledge:** Extensive understanding of CPT, HCPCS, ICD, UB-04 revenue codes, modifiers, billing practices, and applicable government and commercial payer regulations and guidelines. - **Revenue integrity expertise:** Strong understanding of charge capture, revenue integrity principles, and the ability to defend appropriately assigned charges through clinical and financial appeals. - **Clinical validation skills:** Ability to assess and defend assigned diagnoses using clinical evidence, patient documentation, and relevant medical necessity criteria. - **Electronic medical record proficiency:** Ability to navigate electronic medical records efficiently, understand services provided, and connect clinical documentation with billed charges and reimbursement requirements. - **Appeals writing and communication:** Excellent written communication, grammar, and analytical writing skills, with the ability to develop individualized, concise, evidence-based appeal letters under tight deadlines. - **Critical thinking and problem-solving:** Strong analytical judgment and the ability to investigate complex cases, interpret clinical and financial information, and identify appropriate resolution strategies. - **Time management and adaptability:** Ability to manage multiple assignments, reprioritize quickly, maintain productivity in a fast-paced environment, and adapt to evolving payer policies and reimbursement regulations. - **Independent work ethic:** Self-motivated, detail-oriented, and capable of working effectively with limited day-to-day supervision while maintaining high standards of accuracy and quality. - **Technical proficiency:** Proficiency in Microsoft Word, Excel, and Outlook, as well as regular use of Microsoft Teams for communication, collaboration, and virtual meetings. - **Remote work readiness:** Ability to independently set up and maintain a reliable home-office technology environment, including monitors, docking stations, and peripherals, with dependable internet access and a backup internet plan for outages. - **Preferred professional experience:** Background in denial management, utilization review, utilization management, case management, clinical documentation improvement, revenue integrity, or a related healthcare field. - **Preferred certifications:** Certified Case Manager (CCM), Certified Clinical Documentation Specialist (CCDS), or Accredited Case Manager (ACM) credentials are advantageous. - **Preferred payer knowledge:** Familiarity with interpreting payer contractual language and applying contractual requirements to clinical denial reviews and appeals. - **Background screening:** Willingness to complete applicable employment screening requirements, including Florida Level 2 background screening and fingerprinting when required by law. ## Benefits - **Competitive annual salary:** Compensation ranging from **$71,385.60 to $132,787.20**, depending on qualifications and applicable compensation factors. - **Fully remote work:** Work remotely in a full-time position. - **Healthcare coverage from day one:** Medical, dental, and vision insurance. - **Life and disability insurance:** Coverage options to support employees and their families. - **Paid time off:** PTO available beginning on the first day of employment. - **Retirement savings:** Access to a 403(b) retirement plan. - **Paid parental leave:** Four weeks of parental leave at 100% pay. - **Career development:** Opportunities for professional learning, career growth, and continued development of clinical and revenue cycle expertise. - **Whole-person well-being:** Access to wellness resources and programs that support physical, emotional, and overall well-being. - **Mental health support:** Resources designed to support employee mental health and wellness. - **Additional perks:** Pet-related benefits and other employee resources. - **Meaningful professional impact:** Opportunity to apply clinical expertise to complex reimbursement challenges, strengthen revenue integrity, and help healthcare teams prevent avoidable claim denials.