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EnableComp logo
EnableComp

We partner with over 1,000 healthcare providers to maximize their complex claims reimbursements.

Senior Director, Clinical Denials

DirectorDirectorOtherRemoteSeniorTeam 501-1,000H1B No SponsorCompany SiteLinkedIn

Location

Tennessee

Posted

124 days ago

Salary

0

Seniority

Senior

Bachelor Degree10 yrs expEnglish

Job Description

Senior Director, Clinical Denials

EnableComp

• Serve as the vendor’s lead clinical subject matter expert on clinical denials management and prevention. • Partner with provider clients to design and implement best practices for denial prevention and appeal workflows. • Conduct complex clinical case reviews for DRG validation, identifying and defending clinically appropriate DRG assignments. • Develop and refine clinical appeal strategies and templates to improve success rates. • Analyze denial trends across multiple clients and provide actionable insights to reduce recurring clinical denials. • Collaborate with coding, Clinical Documentation Integrity (CDI), and client operations teams to ensure consistency in methodologies and documentation practices. • Support proposal and implementation teams by contributing clinical expertise to solution design and client onboarding. • Maintain deep familiarity with Centers for Medicare & Medicaid Services (CMS) regulations, payer guidelines, and medical necessity criteria such as InterQual and MCG Health (formerly Milliman Care Guidelines). • Represent the organization as a clinical expert in client meetings, audits, and appeal escalations. • Represent EnableComp as an industry expert at national and regional conferences, networking opportunities, community outreach events, and client meetings. • Serve as a spokesperson for the company through webinars, speaking engagements, panel discussions, and authored articles. • Develop white papers, policy briefs, industry reports, and thought leadership content to elevate the organization's presence in the RCM and policy landscape. • Engage with payers and provider networks to advocate for streamlined administrative processes, and enhanced reimbursement methodologies. • Lead client education sessions and internal training programs on Medicare Severity Diagnosis Related Group (MS-DRG) and All Patient Refined Diagnosis Related Group (APR-DRG) validation, clinical documentation integrity, and payer policy application. • Partner with the sales and client success teams to educate prospective and existing clients on EnableComp’s services, value proposition, and regulatory insights. • Provide in-depth RCM expertise in responding to RFPs, proposals, and client inquiries. • Conduct training sessions and presentations on complex claims and industry trends for internal teams and clients.

Job Requirements

  • Bachelor’s Degree
  • Registered Nurse (RN) with at least 10 years of acute care clinical experience (ICU, Medical-Surgical, or similar).
  • 5+ years of experience in clinical denials management or revenue integrity, with strong emphasis on DRG assignment and appeal writing.
  • Excellent written communication and clinical reasoning skills for crafting persuasive appeals and client documentation.
  • Strong knowledge of MS-DRG and APR-DRG methodologies, including Severity of Illness (SOI) and Risk of Mortality (ROM) classifications.
  • Proficiency with CMS rules, payer contracts, and medical necessity guidelines (InterQual, MCG).
  • Regular and predictable attendance.
  • Equivalent combination of education and experience will be considered.

Benefits

  • Flexibility for remote work
  • Commitment to employee growth and development

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