Clinical Denials and Appeals Specialist

<p>We are seeking an experienced Clinical Denials and Appeals Specialist to join our Denials Management team. This role is responsible for reviewing complex payer denials and developing high-quality, evidence-based appeal letters that maximize reimbursement recovery for our healthcare clients.</p>

<p>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. The majority of this role is dedicated to appeal generation, appeal strategy, and overturning clinical denials.</p>

<p><strong>Key Responsibilities</strong></p>

<p><strong>Appeal Development and Submission</strong></p>

<ul>

<li>Generate comprehensive first-level, second-level, and escalated appeal letters for denied claims.</li>

<li>Develop compelling clinical arguments using medical records, physician documentation, industry standards, and payer policies.</li>

<li>Create appeal packages with all required supporting documentation and submit within payer timelines.</li>

<li>Track appeal status, deadlines, and outcomes to ensure timely follow-up.</li>

<li>Review and revise appeal content to improve quality, consistency, and overturn success rates.</li>

</ul>

<p><strong>Clinical Denial Analysis</strong></p>

<ul>

<li>Review and assess denials related to:</li>

<ul>

<li>Medical necessity</li>

<li>Level of care</li>

<li>Clinical validation</li>

<li>Authorization issues</li>

<li>Audit findings</li>

</ul>

<li>Conduct detailed chart reviews to validate payer rationale and determine appeal viability.</li>

<li>Analyze denial trends and identify opportunities for overturn and prevention.</li>

</ul>

<p><strong>Regulatory and Clinical Research</strong></p>

<ul>

<li>Apply CMS regulations, Medicare guidelines, LCDs, NCDs, payer policies, and industry guidance to support appeal arguments.</li>

<li>Maintain current knowledge of ICD-10-CM/PCS coding requirements, DRG methodologies, and reimbursement regulations.</li>

<li>Monitor payer updates and regulatory changes impacting denials and appeals.</li>

</ul>

<p><strong>Collaboration and Process Improvement</strong></p>

<ul>

<li>Assist in developing appeal templates, reference materials, and best practices.</li>

<li>Provide recommendations to improve appeal effectiveness and reduce future denials.</li>

<li>Contribute to denial prevention initiatives through trend analysis and education.</li>

<li>As needed, Partner with physicians, CDI specialists, case management, utilization review, coding, and HIM teams to strengthen appeal outcomes.</li>

</ul>

<p><strong>Required Qualifications</strong></p>

<ul>

<li>Active Registered Nurse (RN) license required; BSN preferred.</li>

<li>Minimum 5 years of clinical nursing experience.</li>

<li>Minimum 3–5 years of denials management & appeals generation.</li>

<li>Demonstrated success generating and overturning clinical denials.</li>

<li>Strong knowledge of:</li>

<ul>

<li>Medical necessity criteria</li>

<li>DRG reimbursement methodology</li>

<li>ICD-10-CM/PCS</li>

<li>CPT/HCPCS</li>

<li>Medicare and Medicaid regulations</li>

<li>Commercial payer policies</li>

</ul>

<li>Experience using InterQual and/or MCG criteria.</li>

<li>Strong proficiency in Microsoft Word and healthcare documentation systems.</li>

<li>Exceptional written communication and persuasive writing skills.</li>

</ul>

<p><strong>Preferred Qualifications</strong></p>

<ul>

<li>Background in critical care, emergency department, operating room, case management, or utilization review.</li>

<li>CDI (Clinical Documentation Integrity) experience.</li>

<li>Familiarity with Epic.</li>

<li>Experience analyzing denial data and reporting trends</li>

</ul>

<p> </p>

<p><strong>Why UASI?</strong></p>

<p>UASI is the employer of choice due to our outstanding reputation for excellence within the industry and for our comprehensive benefit package which includes:</p>

<ul>

<li>Medical, dental, vision and life insurance, short/long-term disability, 401(K) and referral bonuses</li>

<li>Training opportunities and reimbursement for professional certifications</li>

<li>UASI's unique approach to employee appreciation which include birthday recognition, holiday gift selections, performance awards, and years of service awards</li>

</ul>