Stanford Health Care is a division of Stanford Medicine—a segment of Stanford University. As an employer, Stanford Health Care has offered job opportunities t
Senior Clinical Denials Appeal Specialist
Location
United States
Posted
3 days ago
Salary
$67 - $88 / hour
Seniority
Senior
No structured requirement data.
Job Description
Senior Clinical Denials Appeal Specialist
Stanford Medicine
Role Description The Senior Clinical Denials Appeal Specialist serves as a clinical subject matter expert focused on resolving and appealing clinically related, documentation-related, and clinical operations-related denials. This role performs detailed account and medical record reviews to assess and determine appropriate resolution activity, takes necessary actions to resolve clinical denials, and prepares compliant, evidence-based appeal submissions when needed. The Senior Clinical Denials Appeal Specialist operates under established guidelines and supervision, ensuring accurate, timely, and consistent appeal decisions aligned with clinical criteria, regulatory requirements, and organizational standards. - Evaluates clinically related denials and takes necessary actions to resolve, including preparing and submitting clinical appeal arguments and appeals to government, commercial, and managed care payers in accordance with federal, state, and local regulatory requirements. - Conducts thorough analyses of assigned denials, evaluating the clinical validity of diagnoses, appropriateness of medical services and procedures. - Ensures all appeal submissions are accurate, compliant, and submitted within required timelines. - Identifies missing or insufficient documentation and collaborates with internal departments to obtain needed information. - Maintains detailed and accurate documentation of appeal activity in designated systems. - Meets productivity, quality, and turnaround time expectations. - Follows standardized workflows, templates, and escalation protocols. - Operates within established guidelines with supervisory support as needed. Qualifications - Bachelor’s Degree (BSN) is highly preferred. Diploma or Associate’s Degree in Nursing accepted when accompanied by strong demonstrated competencies and significant experience. - Minimum of five (5) years in nursing with a minimum of two (2) years’ experience as Utilization Management Nurse in an acute care setting required. UM or CM leadership experience preferred. - Experience and working knowledge of 2 Midnight, Milliman, and InterQual Guidelines required. - Minimum of two (2) years of experience in denial prevention, denial recovery, clinical appeals, or related denial-management responsibilities within a healthcare setting. - Experience with Epic HB and PB highly desirable. Requirements - Strong understanding of ICD-10-CM/PCS, CPT/HCPCS coding, and medical necessity guidelines. - Strong understanding of clinical operations within a hospital or ambulatory care setting. - Strong understanding of 2 Midnight, Milliman, and InterQual Guidelines. - Familiarity with payer policies, reimbursement methodologies, and CMS guidelines (including Medicare/Medicaid rules) and common commercial payer practices. - Knowledge of CDI concepts, documentation standards, and revenue cycle processes. - Ability to establish and maintain effective working relationships. - Working knowledge of hospital and physician revenue cycle systems, including Epic. Licenses and Certifications - CA Registered Nurse - Valid license as a Registered Nurse issued by the California Board of Registered Nursing (BRN). - CCRC - Cert Clin Resch Coord preferred. Benefits - SHC Commitment to Providing an Exceptional Patient & Family Experience. - Equal Opportunity Employer - Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. - Base Pay Scale: Generally starting at $66.52 - $88.14 per hour.
Related Guides
Related Job Pages
More Clinical Specialist Jobs
Clinical Data Management Specialist
TeleflexThe Interventional business unit at Teleflex develops innovative medical devices used to diagnose and treat coronary and peripheral vascular diseases. We focus strategically on coronary and peripheral interventions, vascular and bone access, and large-bore closure solutions. Our portfolio includes a broad range of clinically relevant products, such as the GuideLiner™ and Turnpike™ Catheters; the Orsiro™ Mission™ Drug-Eluting Stent; the PK Papyrus™ Covered Coronary Stent; the Ringer™ Perfusion Balloon Catheter; the Pulsar™ -18 T3 Self-Expanding Stent; Passeo™ Balloon Catheters; and the OnControl™ Powered Bone Access System. Backed by a strong R&D pipeline, our rapidly growing Interventional business unit is well positioned to continue advancing new technologies that support the treatment of critically ill patients. Join a dynamic team dedicated to delivering innovative medical solutions that make a meaningful difference in patients’ lives.
• Review and contribute to the authorship of protocols and other study documentation, promoting consistency across and within the business unit. • Effectively communicate Data Management requirements, strategies, timelines, and deliverables. • Develop Electronic eCRFs, program edit/rule checks, query logic, and generate database specifications using systems such as Veeva CDMS Vault (or equivalent EDC platforms). • Lead the process for study team review of the following: eCRF Screen review(s), Edit/Rule review, including EDC database specification process with study team(s). • Create User Acceptance test scripts, execution logs for User Acceptance Testing (UAT), and engage the Study team for testing participation. • Develop eCRF Completion Guidelines according to study design, promoting quality data. • Develop and maintain the Data Management Plan (DMP) throughout the lifecycle of the study, ensuring the DMP is followed according to study design and requirements. • Manage in-stream data cleaning and validation for in-house studies, accounting for Interim Analysis, abstract deliverables, and final database locks, while supporting data analysis and reporting. • Generate study metric reports related to Query Management, site performance, and SDV, but not limited to these activities. • Oversee, review, and approve Contract Research Organization (CRO) Data Management Plans, CRF Completion Guidelines, external data transfer agreements, and other study documentation as applicable. • Coordinate data deliverables with the CRO for studies fully outsourced for Data Management. • Conduct DMP and EDC training to internal teams and sites and develop and update training manuals. • Organize ongoing data review to ensure the highest caliber data, on time, in conjunction with monitoring and data locks. • Follow and maintain procedures for filing study files. • Recognize process improvement needs and proactively implement efficient solutions, including SOPs and Work Instructions (WI) development. • Partner with management to manage external vendors, including ongoing supplier qualification and accountability. • Contribute to the development and implementation of departmental policies, standards, and process improvement initiatives. • Responsible for the set-up of the Trial Master File (TMF) and archiving artifacts throughout the study life cycle. • Contribute to our culture of being collaborative, respectful, transparent, ethical, efficient, high-achieving, and fun!
Senior Clinical Specialist, Cardiac Rhythm Management
AbbottAs an employer, Abbott is interested in candidates who are passionate about creating healthy solutions and making a difference in the world. Abbott offers compe
• Provide comprehensive engineering, sales, educational, and technical support. • Respond to field inquiries from physicians, healthcare professionals, patients, and field sales staff regarding CRM (Cardiac Rhythm Management) products. • Acts as a clinical interface between the medical community and the business. • Builds and sustains credible business relationships with customers and shares product expertise accordingly. • Provides engineering, sales, education, and clinical support in response to field inquiries on an as-needed basis. • Demonstrates a thorough command of all CRM products, related product and technical knowledge, trends, and players. • Develops, leads, and/or facilitates training sessions and other programs on CRM products for healthcare professionals. • Provides additional back-up support to CRM Sales Representatives.
• Provides technical leadership regarding implantation and utilization of Medtronic Surgical Based Therapy products and procedures. • Educates physicians, physician assistants, perfusionists, and operating room staff on indications, procedural techniques, and appropriate use of SBT products. • Develops and maintains comprehensive clinical and technical product knowledge. • Assists and serves as a consultant to physicians, customers, and sales staff with troubleshooting and management of complex procedural challenges. • Serves as a clinical resource during physician adoption and growth phases. • May assist field and Medical Affairs teams with customer communication regarding device complaints, product evaluations, and explants. • Provides technical expertise and leadership to support safe and effective adoption of Medtronic technologies. • Collaborates with sales personnel on physician targeting and attendance at Medtronic-sponsored training programs. • Engages with physicians and clinical teams before, during, and after attendance at educational events. • Provides post-training follow-up, procedural reviews, in-servicing, and first-case support. • Supports minimally invasive cardiac surgery (MICS) and advanced procedural training initiatives. • Participates in dissemination of peer-reviewed scientific and clinical information. • Develops and maintains influential relationships with key customers and physician leaders. • Provides procedural support and clinical coverage during physician adoption and growth phases. • Supports onboarding and development of new sales representatives and clinical specialists. • Provides technical expertise for regional education and training activities. • Assists with physician, resident, fellow, and advanced practice provider educational programs. • Delivers competitive and product training to sales representatives and clinical specialists. • Partners with District Managers and Territory Managers to communicate and execute resident and fellow development initiatives. • Maintains relationships with attending surgeons and academic institutions throughout the territory. • Supports early-career surgeon education programs and procedural training opportunities. • Assists in development and execution of future physician education initiatives. • Maintains expertise in competitive technologies and therapies. • Effectively communicates competitive information, market trends, and clinical evidence to field teams. • Remains current regarding peer-reviewed publications, clinical data, and evolving standards of care. • Delivers clinical and competitive training to field personnel. • Schedules travel arrangements to ensure multiple objectives are accomplished efficiently. • Maintains hospital access and vendor credentialing requirements. • Completes expense reports accurately and in a timely manner. • Maintains all required training and compliance certifications. • Effectively manages time, resources, and priorities across a large geography. • Maintains a high level of communication with Territory Managers, District Managers, Area Leadership, Marketing, Medical Affairs, and key stakeholders. • Ensures a professional standard of written and verbal communication at all times. • Collaborates effectively across functions to support physician adoption, account development, and business growth initiatives.
• Build trusted relationships with radiation oncologists, dosimetrists, therapists, and clinical care teams to understand their workflows and business needs. • Conduct workflow discovery sessions with customers to identify opportunities for product improvement and optimization. • Serve as the clinical expert during product demonstrations, customer meetings, implementations, and industry events. • Gather customer feedback and translate clinical workflows into detailed product requirements, workflow documentation, and user stories. • Collaborate closely with Product Managers, UX designers, and software engineers to ensure customer needs are reflected in future product enhancements. • Document physician workflows, decision points, and clinical processes to support product development and regulatory requirements. • Assist Sales by answering complex clinical questions and providing subject matter expertise throughout the sales cycle.




