Clinical Appeals Senior Consultant

About the role

As a Clinical Appeals Senior Consultant, you serve as a strategic liaison between clinical and financial stakeholders, ensuring healthcare services are accurately documented, coded, billed, and reimbursed by leading clinical appeals, denial management, and chart audit initiatives.

Responsibilities

• Manage assigned customer engagements from initiation through completion, ensuring timelines, deliverables, and budgets stay on track.
• Design and optimize workflows by documenting current-state processes and implementing future-state solutions aligned to best practices.
• Lead clinical appeals and denial management activities by reviewing denials, identifying root causes, and developing prevention strategies.
• Evaluate clinical documentation, medical necessity, and payer guidelines to create evidence-based, defensible appeal strategies.
• Produce high-quality appeal letters and present at hearings (e.g., ALJ) to support successful claim resolution.
• Analyze denial trends, audit findings, and operational data to provide actionable insights that reduce denials and improve performance.
• Conduct detailed chart audits to assess documentation accuracy, coding alignment, and compliance with regulatory standards.
• Partner with customers as a trusted advisor, delivering education, coaching, and strategic guidance to improve documentation and workflows.
• Collaborate cross-functionally with internal teams (product, sales, and services) to deliver a consistent, high-quality customer experience.
• Ensure compliance with HIPAA, payer requirements, and appeal deadlines while maintaining accurate documentation and data integrity.

Requirements

• Active RN, BSN, or clinically relevant licensure required.
• CCS or CPC certification required.
• Minimum 7+ years of experience in appeals, denials management, chart auditing, or clinical documentation review.
• Strong knowledge of medical necessity, payer policies, and revenue cycle operations.
• Proven ability to manage customer-facing engagements and lead process improvement initiatives.
• Exceptional written communication with ability to produce defensible clinical appeal documentation.
• Strong analytical and problem-solving skills with focus on root cause identification.
• Proficiency in EHR systems, clinical documentation tools, and revenue cycle platforms.
• Ability to translate complex clinical and regulatory concepts into actionable insights.
• Effective stakeholder engagement and relationship-building skills.
• Travel up to 10%.