Denials Management Specialist

Denials Management Specialist

Under the direction of departmental leadership, the Denial Management Specialist plays a critical role in managing medical, authorization, and reimbursement-related denials. This role supports organizational initiatives aimed at ensuring timely access to medically necessary services, appropriate reimbursement, and regulatory compliance. The Denial Management Specialist independently navigates complex payer requirements, applies clinical judgment to appeal strategies, analyzes denial trends, and collaborates across teams to resolve denials efficiently.

Responsibilities:

• Independently manage denial mitigation activities, including peer-to-peer reviews, expedited appeals, standard appeals, and retrospective reviews. Prioritize denials based on clinical urgency, potential delay of care, financial impact, payer timelines, and regulatory requirements. Review denial notifications, clinical documentation, and payer correspondence to determine appropriate appeal strategies. Facilitate and coordinate peer-to-peer discussions by ensuring providers are prepared with relevant clinical information, payer criteria, and supporting documentation. Escalate complex, high-risk, or time-sensitive denials according to established protocols.
• Apply clinical judgment to evaluate medical necessity, authorization criteria, treatment plans, and supporting medical record documentation. Identify documentation gaps and collaborate with clinical teams to strengthen records supporting payer compliance and appeal success. Differentiate clinical versus administrative denials to determine appeal eligibility and resolution pathways. Support retrospective review processes for previously denied services requiring additional clinical or authorization intervention.
• Maintain a working knowledge of payer policies, authorization requirements, appeal rights, timelines, and reimbursement rules. Interpret payer contracts, benefit structures, and clinical criteria to ensure all allowable appeal and resolution options are pursued. Monitor compliance with applicable regulatory, accreditation, and organizational standards. Maintain accurate documentation to support audits, reporting, and regulatory readiness.
• Monitor denial trends by payer, diagnosis, service type, and treatment modality. Analyze denial data to identify root causes, patterns, and opportunities for process improvement. Share findings with leadership and stakeholders to support denial prevention and workflow enhancements. Contribute to reporting, dashboards, and quality improvement initiatives related to denial management.
• Partner with revenue, managed care, patient access, pharmacy, and clinical teams to support timely denial resolution and reimbursement. Serve as a liaison between internal teams and payers to facilitate communication and resolution of complex cases. Participate in interdisciplinary meetings, work groups, and committees related to denial management and prevention.
• Serve as a subject matter expert for denial management workflows, prioritization standards, and escalation pathways. Educate and support team members on payer requirements, clinical criteria, appeal processes, and documentation best practices. Assist with onboarding and training of new staff related to denial and appeal workflows. Provide ongoing guidance and problem-solving support to peers.
• Perform other duties as assigned to support departmental and organizational objectives. Adapt responsibilities as payer requirements, workflows, and organizational needs evolve.

How You'll Be Successful:

• WORK EXPERIENCE: At least 3 years Authorization Experience, UM, CM or denial Management Required. At least 5 years Clinical nursing experience Preferred.
• EDUCATION: Four-year Bachelor's degree or equivalent experience Required.
• LICENSES AND CERTIFICATIONS: RN Required.

A Place Where You Belong

We put our people first. We welcome, value, and respect the beliefs, identities and experiences of our patients and colleagues. We are committed to delivering culturally effective care, creating meaningful partnerships in the communities we serve, and equipping and developing our team members to make Children's Health a place where everyone can contribute.

Holistic Benefits How We'll Care for You:

• Employee portion of medical plan premiums are covered after 3 years.
• 4%-10% employee savings plan match based on tenure
• Paid Parental Leave (up to 12 weeks)
• Caregiver Leave
• Adoption and surrogacy reimbursement

As an equal opportunity employer, Children's Health does not discriminate against employees or applicants because of race, color, religion, sex, gender identity and expression, sexual orientation, age, national origin, veteran or military status, disability, or genetic information or any other Federal or State legally protected status or class. This applies to all aspects of the employer-employee relationship including but not limited to recruitment, hiring, promotion, transfer pay, training, discipline, workforce adjustments, termination, employee benefits, and any other employment-related activity.

Children's Health System of Texas