Clinical Denials and Appeals Specialist

About the Role

We are seeking an experienced Clinical Denials and Appeals Specialist to join our Denials Management team. This role focuses on reviewing complex payer denials and developing high-quality, evidence-based appeal letters to maximize reimbursement recovery for our healthcare clients. The ideal candidate is a strong clinical reviewer and exceptional writer who can analyze medical records, identify weaknesses in payer determinations, and craft persuasive appeals supported by clinical documentation, regulatory guidance, and payer-specific requirements.

Responsibilities

• Appeal Development and Submission
  • Generate comprehensive first-level, second-level, and escalated appeal letters for denied claims.
  • Develop compelling clinical arguments using medical records, physician documentation, industry standards, and payer policies.
  • Create appeal packages with all required supporting documentation and submit within payer timelines.
  • Track appeal status, deadlines, and outcomes to ensure timely follow-up.
  • Review and revise appeal content to improve quality, consistency, and overturn success rates.
• Clinical Denial Analysis
  • Review and assess denials related to:
    • Medical necessity
    • Level of care
    • Clinical validation
    • Authorization issues
    • Audit findings
  • Conduct detailed chart reviews to validate payer rationale and determine appeal viability.
  • Analyze denial trends and identify opportunities for overturn and prevention.
• Regulatory and Clinical Research
  • Apply CMS regulations, Medicare guidelines, LCDs, NCDs, payer policies, and industry guidance to support appeal arguments.
  • Maintain current knowledge of ICD-10-CM/PCS coding requirements, DRG methodologies, and reimbursement regulations.
  • Monitor payer updates and regulatory changes impacting denials and appeals.
• Collaboration and Process Improvement
  • Assist in developing appeal templates, reference materials, and best practices.
  • Provide recommendations to improve appeal effectiveness and reduce future denials.
  • Contribute to denial prevention initiatives through trend analysis and education.
  • Partner with physicians, CDI specialists, case management, utilization review, coding, and HIM teams to strengthen appeal outcomes as needed.

Requirements

• Active Registered Nurse (RN) license required; BSN preferred.
• Minimum 5 years of clinical nursing experience.
• Minimum 3–5 years of denials management and appeals generation.
• Demonstrated success generating and overturning clinical denials.
• Strong knowledge of:
  • Medical necessity criteria
  • DRG reimbursement methodology
  • ICD-10-CM/PCS
  • CPT/HCPCS
  • Medicare and Medicaid regulations
  • Commercial payer policies
• Experience using InterQual and/or MCG criteria.
• Strong proficiency in Microsoft Word and healthcare documentation systems.
• Exceptional written communication and persuasive writing skills.

Preferred Qualifications

• Background in critical care, emergency department, operating room, case management, or utilization review.
• CDI (Clinical Documentation Integrity) experience.
• Familiarity with Epic.
• Experience analyzing denial data and reporting trends.

Benefits

• Medical, dental, vision, and life insurance.
• Short/long-term disability.
• 401(K) and referral bonuses.
• Training opportunities and reimbursement for professional certifications.
• Employee appreciation programs, including:
  • Birthday recognition
  • Holiday gift selections
  • Performance awards
  • Years of service awards