Clinical Denials and Appeals Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Produce thorough first-level, second-level, and escalated appeal letters for claims that have been denied.

• Craft persuasive clinical arguments utilizing medical records, physician documentation, industry standards, and payer policies.

• Assemble appeal packages containing all necessary supporting documentation and ensure submission within payer deadlines.

• Monitor the status of appeals, track deadlines, and outcomes to facilitate prompt follow-up.

• Review and refine appeal content to enhance quality, consistency, and success rates in overturning decisions.

• Examine and evaluate denials concerning:

• Medical necessity

• Level of care

• Clinical validation

• Authorization issues

• Audit findings

• Perform comprehensive chart reviews to confirm payer rationale and assess the viability of appeals.

• Investigate denial patterns and pinpoint opportunities for overturning and prevention.

• Implement CMS regulations, Medicare guidelines, LCDs, NCDs, payer policies, and industry standards to bolster appeal arguments.

• Stay updated on ICD-10-CM/PCS coding requirements, DRG methodologies, and reimbursement regulations.

• Keep track of payer updates and regulatory changes that affect denials and appeals.

• Aid in the creation of appeal templates, reference materials, and best practices.

• Offer suggestions to enhance appeal effectiveness and minimize future denials.

• Participate in denial prevention strategies through trend analysis and educational initiatives.

• Collaborate with physicians, CDI specialists, case management, utilization review, coding, and HIM teams to improve appeal outcomes.

⛳️ Requirements

• Current Registered Nurse (RN) license is required; BSN is preferred.

• At least 5 years of clinical nursing experience is necessary.

• A minimum of 3–5 years of experience in denials management and appeal generation.

• Proven track record of generating and overturning clinical denials.

• In-depth understanding of:

• Medical necessity criteria

• DRG reimbursement methodology

• ICD-10-CM/PCS

• CPT/HCPCS

• Medicare and Medicaid regulations

• Policies from commercial payers

• Familiarity with InterQual and/or MCG criteria is beneficial.

• Strong skills in Microsoft Word and healthcare documentation systems.

• Excellent written communication and persuasive writing abilities.

🏝️ Benefits

• Medical, dental, vision, and life insurance

• Short and long-term disability coverage

• 401(K) plan and referral bonuses

• Opportunities for training and reimbursement for professional certifications

• UASI's distinctive approach to employee appreciation, which includes birthday recognition, holiday gift selections, performance awards, and years of service awards