Clinical Denials and Appeals Specialist

Clinical SpecialistGeneralFull TimeRemoteSeniorTeam 1-10Since 2001H1B No SponsorCompany SiteLinkedIn

Location

United States

Posted

12 hours ago

Salary

0

Seniority

Senior

Professional Certificate5 yrs expEnglish

Job Description

Clinical Denials and Appeals Specialist

Affordable Housing Trust for Columbus and Franklin County

• Generate comprehensive first-level, second-level, and escalated appeal letters for denied claims. • Develop compelling clinical arguments using medical records, physician documentation, industry standards, and payer policies. • Create appeal packages with all required supporting documentation and submit within payer timelines. • Track appeal status, deadlines, and outcomes to ensure timely follow-up. • Review and revise appeal content to improve quality, consistency, and overturn success rates. • Review and assess denials related to: • Medical necessity • Level of care • Clinical validation • Authorization issues • Audit findings • Conduct detailed chart reviews to validate payer rationale and determine appeal viability. • Analyze denial trends and identify opportunities for overturn and prevention. • Apply CMS regulations, Medicare guidelines, LCDs, NCDs, payer policies, and industry guidance to support appeal arguments. • Maintain current knowledge of ICD-10-CM/PCS coding requirements, DRG methodologies, and reimbursement regulations. • Monitor payer updates and regulatory changes impacting denials and appeals. • Assist in developing appeal templates, reference materials, and best practices. • Provide recommendations to improve appeal effectiveness and reduce future denials. • Contribute to denial prevention initiatives through trend analysis and education. • Partner with physicians, CDI specialists, case management, utilization review, coding, and HIM teams to strengthen appeal outcomes.

Job Requirements

  • Active Registered Nurse (RN) license required; BSN preferred.
  • Minimum 5 years of clinical nursing experience.
  • Minimum 3–5 years of denials management & appeals generation.
  • Demonstrated success generating and overturning clinical denials.
  • Strong knowledge of:
  • Medical necessity criteria
  • DRG reimbursement methodology
  • ICD-10-CM/PCS
  • CPT/HCPCS
  • Medicare and Medicaid regulations
  • Commercial payer policies
  • Experience using InterQual and/or MCG criteria.
  • Strong proficiency in Microsoft Word and healthcare documentation systems.
  • Exceptional written communication and persuasive writing skills.

Benefits

  • Medical, dental, vision and life insurance
  • short/long-term disability
  • 401(K) and referral bonuses
  • Training opportunities and reimbursement for professional certifications
  • UASI's unique approach to employee appreciation which include birthday recognition, holiday gift selections, performance awards, and years of service awards

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