Preserving, Creating & Facilitating
Clinical Denials and Appeals Specialist
Location
United States
Posted
12 hours ago
Salary
0
Seniority
Senior
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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