Clinical Denials Specialist

Duties And Responsibilities

• Ability to analyze denial reasons and trends to identify opportunities for process improvement.
• Excellent verbal and written communication skills to effectively collaborate with healthcare providers and present appeal arguments.
• Keen attention to detail to ensure accurate review and analysis of denied claims and medical records.
• Strong problem-solving skills to develop effective appeal strategies and overcome denial challenges.
• Understanding of medical terminology, coding principles, and reimbursement guidelines to assess denial reasons and appeal opportunities.
• Ability to adapt to changing payer policies, regulations, and reimbursement requirements.
• Review denied claims to identify denial reasons and discrepancies.
• Analyze medical records, billing documents, and payer policies to prepare appeal arguments.
• Collaborate with healthcare providers to gather additional documentation and evidence for appeals.
• Document appeal activities, correspondence, and outcomes for tracking and reporting purposes.
• Monitor denial trends and provide feedback to revenue cycle teams to prevent future denials.
• Participate in denial management meetings and contribute insights to improve denial prevention strategies.
• Stay updated on payer policies, regulations, and reimbursement guidelines relevant to claim denials.

Requirements

• Bachelor's degree in healthcare administration, nursing, health information management, or a related field.
• Clinical designated nurse, RN credentials (denials/CDI).
• Minimum of 2-3 years of experience in healthcare revenue cycle management, medical billing, claims processing, or denial management.

Physical Demands and Work Environment

• This job operates in a professional home environment.
• This role routinely uses standard office equipment such as computers, and phones.
• This is largely a sedentary role; however, employees may need to use keyboards, mouse, and other devices for typing, clicking, and navigating software systems.