Denials Management Specialist

At Houston Methodist, the Denials Management Specialist (DMS) position is responsible for reviewing, coordinating, and monitoring the clinical denial management and appeals process, reducing significant financial risk caused by concurrent and retrospective denial of payments for services provided. The role combines clinical, business, and regulatory knowledge to manage denials for level of care, medical necessity, Diagnosis Related Group (DRG) recoupments/downgrades, no authorization, and audit reviews, collaborating with physicians, case managers, revenue cycle personnel, and payors to successfully appeal technical and clinical denials.

FLSA STATUS

Exempt

QUALIFICATIONS

Education Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section. Bachelor of Science preferred Experience Seven years clinical nursing/patient care experience with five years in utilization review using tools such as Interqual, Millimann, etc., or equivalent revenue cycle clinical role, including experience in initiating and facilitating physician peer‑to‑peer review, medical/clinical denials and appeals. Must have experience with prior authorization processes for all providers, ordering and rendering. Licenses, Certifications, and Registrations Required LVN – Licensed Vocational Nurse – State Licensure (Texas Department of Licensing and Regulation, PSV license in Texas) Preferred CPHM – Certified Professional in Healthcare Management (McKesson) CCM – Certified Case Manager (CCMC) ACM – Accredited Case Manager (NBCM,ACMA) or equivalent Skills and Abilities Demonstrates the skills and competencies necessary to safely perform the assigned job, assessed through ongoing evaluations. Proficient in speaking, reading, and writing English, especially in safety‑critical activities. Communicates effectively with patients, physicians, families, and co‑workers, applying a customer‑service focus. Extensive knowledge of clinical symptomology, treatment, and hospital utilization management. Knowledge of commercial, managed‑care, and governmental reimbursement models and ability to write technical appeal letters and reports. Communicates both verbally and in writing to all personnel levels, physicians, clinical staff, management, and revenue cycle staff. Motivated and capable of working independently with minimal supervision. Excellent listening skills. Knowledge of medical and insurance terminology, and medical record coding (ICD‑10, CPT/HCPCS, etc.). Advanced proficiency in MS Word and basic Excel. Knowledge of electronic health record systems. Effectively collaborates with interprofessional teams, both internal and external to Houston Methodist. Maintains knowledge of federal, state, and local billing regulations and managed‑care contracting. Familiar with ADT, registration, and pre‑admit/admit workflows. Understands contracts, billing, and follow‑up procedures. Strong knowledge of commercial insurance, governmental programs, regulations, and managed‑care contracts, including CPT, ICD codes, and local/national coverage determinations. Capable of writing appeals for medical necessity compliance or level‑of‑care requirements for government and non‑government payors. Develops appeal strategies and facilitates clinical appeals to ensure recovery. Essential Functions People Essential Functions Trains staff on denials and appeals processes, denial management, and medical coverage guidelines; serves as an educational liaison to clinical, revenue‑cycle, central business office, and facility staff on payor denials, denial reasons, trends, and regulatory requirements. Reduces avoidable denials by communicating directly with physicians, case‑management staff, clinical service areas, CBO partners, and vendors, conveying payor requirements and reasons for denials through phone, meetings, email, and written correspondence. Participates in payor meetings and works with local denial‑management and audit‑review groups to identify root causes, apply payor medical policies, and develop successful appeal strategies. Service Essential Functions Provides clinical support for data gathering and reviews; assists in resolving inpatient and outpatient denials and related reimbursement tasks; participates in meetings with case management, revenue cycle, departmental staff, and facility leaders to share denial trends and opportunities for reduction. Monitors CMS and other regulatory sources for updates on authorization and denial management, serving as an educational resource for appeal staff and management. Creates tools, resources, and letter templates for appeal staff, reviewing appropriateness and clinical accuracy; recommends and resolves payor issues related to reimbursement risk and prevention of denials. Quality/Safety Essential Functions Analyzes data from medical records, claims, UM criteria, payor policies, and regulations to determine denial causes and partner with management to implement prevention strategies; integrates policies, documentation, and claims into concise appeal letters, and collaborates with IT and billing managers on software updates. Collects and maintains accurate statistics on denials, payment recovery, and payor requirement changes; reports findings to management and senior leadership. Reviews medical records and remittances to determine root causes; assists in developing corrective action plans within local denial work groups. Finance Essential Functions Works with leadership across patient access, case management, health information management, and clinical operations to reduce denials; identifies root causes such as medical necessity, contractual, experimental, exclusions, level‑of‑care discrepancies, under‑payments, and exhaustion of benefits; evaluates appeal feasibility and strategies. Ensures accurate denial trending data and metrics (CPT/HCPCS, denial reasons, DRG recoupments, appeals); monitors payment recovery and identifies corrective measures. Negotiates with payors for lower levels of care when supported by case management and contract allowances. Assesses process or workflow improvements in denials and collaborates with management to implement them, providing feedback to patient access, coding, and operational leaders. Growth/Innovation Essential Functions Collaborates with third‑party appeal vendors to identify denial and recovery trends and partners with management to strategically improve processes. Leads personal learning and development, seeking continuing education, completing and updating an individual development plan, and engaging in career discussions with management. Supplemental Requirements Work Attire Uniform: No Scrubs: No Business professional: Yes Other (department approved): No On‑Call *Note that employees may be required to be on‑call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below. On Call: No Travel May require travel within the Houston Metropolitan area: Yes May require travel outside Houston Metropolitan area: No #J-18808-Ljbffr Houston Methodist