Clinical Denials Management Specialist

This position is listed on behalf of a partner company, which manages all applications and next steps. Our partner is looking for a Clinical Denials Management Specialist based in the United States. In this fully remote role, you will leverage your clinical expertise and analytical skills to review, investigate, and appeal denied hospital insurance claims across a healthcare system. You will analyze clinical documentation, billing records, payer policies, and patient histories to develop compelling, evidence-based appeals that support appropriate reimbursement. Working closely with nursing, utilization management, revenue integrity, and patient financial services teams, you will help resolve complex denials and identify opportunities to prevent future claim rejections. You will address a broad range of clinical and financial issues, including medical necessity, level-of-care determinations, clinical validation, and charge discrepancies. Your work will directly contribute to revenue integrity, regulatory compliance, and the financial sustainability of healthcare services. This opportunity is ideal for an experienced registered nurse with strong clinical judgment, excellent writing skills, and a passion for improving healthcare reimbursement processes. Accountabilities - Review and appeal clinical denials: Investigate denied hospital claims across clinical services, determine the most appropriate response, and develop comprehensive appeals or alternative resolution strategies based on the available evidence. - Conduct detailed account research: Review patient encounter histories, electronic medical records, payer portals, billing documentation, charge histories, payment records, and other information systems to establish the facts needed for each case.

- Develop individualized appeal letters: Prepare clear, persuasive, and well-supported written appeals that reflect each patient's severity of illness, intensity of services, clinical circumstances, denial category, and supporting documentation. - Defend clinical necessity and validity: Evaluate and challenge denials involving medical necessity, clinical validation, inpatient versus observation status, neonatal intensive care unit (NICU) level of care, readmissions, and services classified as experimental or inconsistent with payer policies. - Address billing and charge-related denials: Investigate charge capture and charge audit issues, identify discrepancies, make appropriate charge corrections, and support accurate rebilling when required. - Apply coding and reimbursement standards: Interpret CPT and HCPCS codes, ICD classifications, UB-04 revenue codes, modifiers, billing guidelines, and relevant government and commercial payer regulations to support appropriate reimbursement. - Collaborate with cross-functional teams: Partner with pre-access, patient financial services, revenue integrity, utilization management, and clinical departments to obtain additional records, clarify clinical details, and strengthen appeal submissions. - Apply utilization review criteria: Evaluate inpatient and observation classifications using established clinical review frameworks, including MCG and InterQual, and incorporate relevant findings into denial defense strategies. - Identify root causes and prevent future denials: Investigate recurring denial patterns, collect supporting evidence, adjust accounts when appropriate, and recommend corrective actions to improve documentation, billing accuracy, and reimbursement outcomes. - Provide education and reporting: Prepare reports on clinical denial trends, share findings with leadership, and deliver education or training on payer requirements, documentation practices, and effective denial prevention strategies. - Interpret payer policies and contracts: Review payer guidelines and contractual language to determine applicable requirements and develop appropriate responses to disputed claims.