Clinical Denial Specialist

Summary

The Clinical Denials Specialist plays a vital role in ensuring accurate reimbursement for healthcare services by reviewing denied claims, identifying denial reasons, and appealing claim denials.

This role collaborates closely with healthcare providers to gather the documentation and clinical evidence needed to build strong appeals, analyzes denial trends across the organization, and provides feedback to revenue cycle teams to help prevent future denials. Success requires a blend of clinical knowledge, coding and reimbursement expertise, and sharp analytical and writing skills.

This is a work from office opportunity for a clinically credentialed professional who wants to make a direct, measurable impact on revenue recovery and denial prevention.

Duties and Responsibilities

Denial Review & Appeals

• Knows, understands, incorporates, and demonstrates the Client Core Values in all interactions with team members, clients, and stakeholders.

• Reviews denied claims to identify denial reasons and discrepancies.

• Analyzes medical records, billing documents, and payer policies to prepare appeal arguments.

• Applies coding knowledge and industry-standard tools to validate diagnoses, procedures, modifiers, and other claim-related information and identify potential coding-related denial issues

• Demonstrates knowledge of inpatient (IP) DRG and level-of-care concepts, including the relationship between clinical documentation, severity of illness, intensity of services, medical necessity, and DRG assignment.

• Collaborates with healthcare providers to gather additional documentation and evidence for appeals.

• Develops effective, well-supported appeal strategies to overcome denial challenges.

• Documents appeal activities, correspondence, and outcomes for tracking and reporting purposes.

Denial Trend Analysis & Process Improvement

• Analyzes denial reasons and trends to identify opportunities for process improvement.

• Monitors denial trends and provides feedback to revenue cycle teams to prevent future denials.

• Participates in denial management meetings and contributes insights to improve denial prevention strategies.

Clinical & Regulatory Knowledge

• Applies knowledge of medical terminology, coding principles, and reimbursement guidelines to assess denial reasons and appeal opportunities.

• Stays updated on payer policies, regulations, and reimbursement guidelines relevant to claim denials.

• Adapts to changing payer policies, regulations, and reimbursement requirements.

Communication & Collaboration

• Communicates clearly and persuasively, both verbally and in writing, to collaborate with healthcare providers and present appeal arguments.

• Applies keen attention to detail to ensure accurate review and analysis of denied claims and medical records.

• Performs other duties as assigned.

Qualifications

Required

• Bachelor’s degree in Healthcare Administration, Nursing, Health Information Management, or a related field.

• Active RN license with clinical denials or Clinical Documentation Improvement (CDI) credentialing.

• Minimum of 2-3 years of experience in healthcare revenue cycle management, medical billing, claims processing, or denial management.

• Strong problem-solving skills with the ability to develop effective appeal strategies.

• Completion of regulatory/mandatory certifications as required.

• Willingness and ability to travel to client or organizational sites as needed.

Preferred

• Certified Denials and Appeals Specialist (CDAS) or equivalent denial management credential.

• Experience with EHR systems, such as Epic, and payer denial management portals.

Physical Demands and Work Environment

• Work Environment: This job operates in a professional home environment. This role routinely uses standard office equipment such as computers and phones.

• Physical Demands: This is largely a sedentary role; however, employees may need to use keyboards, mouse, and other devices for typing, clicking, and navigating software systems.

• The employee must comply with Client’s Code of Conduct, policies, procedures, and guidelines.