Sr. Clinical Denials Prevention Analyst (Remote)

About the role

The Senior Clinical Denials Prevention Analyst serves as a clinical subject matter expert focused on reducing clinically related, documentation-related, and clinical operations-related denials through data and account analysis. The role partners across clinical, operational, revenue cycle, and payer-facing teams to identify patterns, assess root causes, and recommend improvements across the care-to-claim continuum, both before and after claim submission.

Responsibilities

• Analyze denial and write-off data across payers to identify patterns, root causes, and prevention opportunities across clinical, documentation, coding, and charging processes for both pre-bill and post-bill denials.
• Conduct denial reviews to identify gaps in documentation, UM or revenue cycle workflows, coding, and billing rules and collaborate with UM, CDI, coding, and case managers to address gaps and implement corrective actions.
• Lead cross-functional root-cause analyses with UM, CDI, HIM, Coding, Case Management, Billing, and payer teams to design and implement remediation strategies.
• Help develop and implement denial prevention strategies, workflows, and playbooks and monitor their effectiveness through regular KPI reporting.
• Maintain denial dashboards, action plans, and performance reports for leadership review.
• Prepare summary findings of analysis for department leadership; maintain clear documentation of analyses and outcomes; escalate systemic risks and barriers as appropriate.
• Provide root cause analysis and support the mitigation of denial and denial write-off trends.
• Perform standard to moderately complex financial and operational analyses to quantify impact, inform decisions, and track benefits realization.

Requirements

• Minimum of five (5) years in nursing with a minimum of two (2) years’ experience as Utilization Management Nurse in an acute care setting required. UM or CM leadership experience preferred.
• Experience and working knowledge of 2 Midnight, Milliman, and InterQual Guidelines required.
• Experience and working knowledge of payer policies, reimbursement methodologies, and CMS guidelines (including Medicare/Medicaid rules) and common commercial payer practices.
• Knowledge of CDI concepts, documentation standards, and revenue cycle processes.
• Ability to apply high-level problem-solving skills to perform root cause analysis on denied accounts and develop actionable remediation strategies.
• Ability to manage, organize, prioritize, multi-task and adapt to changing priorities.
• Ability to communicate effectively in written and verbal formats including summarizing data, presenting results.
• Ability to establish and maintain effective working relationships.
• Working knowledge of hospital and physician revenue cycle systems, including Epic.

Qualifications

• Bachelor’s Degree (BSN) is highly preferred. Diploma or Associate’s Degree in Nursing accepted when accompanied by strong demonstrated competencies and significant experience.
• CA Registered Nurse - Valid license as a Registered Nurse issued by the California Board of Registered Nursing (BRN).
• CCRC - Cert Clin Resch Coord preferred.

Skills

• Strong understanding of ICD-10-CM/PCS, CPT/HCPCS coding, and medical necessity guidelines.
• Familiarity with payer policies, reimbursement methodologies, and CMS guidelines (including Medicare/Medicaid rules) and common commercial payer practices.
• Knowledge of CDI concepts, documentation standards, and revenue cycle processes.
• Ability to apply high-level problem-solving skills to perform root cause analysis on denied accounts and develop actionable remediation strategies.
• Ability to manage, organize, prioritize, multi-task and adapt to changing priorities.
• Ability to communicate effectively in written and verbal formats including summarizing data, presenting results.
• Ability to establish and maintain effective working relationships.
• Working knowledge of hospital and physician revenue cycle systems, including Epic.

Benefits

Stanford Health Care offers a comprehensive benefits package including medical, dental, vision, retirement, paid time off, and more. Specific details can be found in the employee handbook or by contacting HR.

Pay

Base Pay Scale: Generally starting at $66.52 - $88.14 per hour. The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training.

Schedule

This is a Stanford Health Care job. A Day - 08 Hour schedule is available. Remote work is possible.