Denials Management Specialist

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

📋 Description

• Conduct thorough clinical and regulatory evaluations of records submitted for payer, government, and external audit inquiries.

• Oversee assigned audit reviews from initiation to submission, encompassing ADR, TPE, UPIC, SMRC, RAC, MAC, Medicaid, managed care, and various payer or regulatory assessments.

• Examine medical records for completeness, accuracy, medical necessity, eligibility, certification/recertification support, compliance with plans of care, visit documentation, orders, signatures, and payer-specific stipulations.

• Utilize Medicare, Medicaid, payer, hospice, home health, and internal review criteria to assess claim defensibility.

• Detect documentation gaps, audit risks, technical deficiencies, and common denial causes.

• Compile well-organized audit packets and review summaries for external reviewers, payers, and government contractors.

• Facilitate appeal development by analyzing denied claims and summarizing clinical and regulatory evidence.

• Coordinate audit response activities with various stakeholders, including agencies, clinical operations, revenue cycle, finance, compliance, and legal teams.

• Suggest corrective measures, process enhancements, and targeted training based on audit outcomes and risk patterns.

• Maintain expertise in audit review, tracking, reporting, and healthcare information systems.

⛳️ Requirements

• Registered Nurse or other relevant clinical licensing is highly preferred.

• Equivalent experience in clinical roles, audit, compliance, revenue cycle, or denial management may be considered based on business requirements.

• A minimum of five years' experience in home health, hospice, post-acute care, clinical documentation review, audit responses, appeals, compliance, or denial management is preferred.

• Strong understanding of Medicare, Medicaid, managed care, and payer documentation standards.

• Familiarity with home health and hospice eligibility, medical necessity, certification, recertification, plans of care, orders, signatures, and visit documentation criteria.

• Capability to interpret payer audit requests and determine necessary documentation.

• Skill in evaluating record completeness and accurately organizing submission packets in a timely manner.

• Ability to distill complex clinical, operational, and regulatory information into clear findings, recommendations, and educational opportunities.

• Exceptional written and verbal communication abilities.

• Highly detail-oriented, deadline-focused, and capable of prioritizing competing tasks with minimal oversight.

• Comfortable working independently in a remote setting while collaborating with cross-functional teams.

• Proficient with healthcare information systems, electronic medical records, Microsoft Office, Excel, PDF tools, Smartsheet, payer portals, and audit tracking or reporting tools.

🏝️ Benefits

• CAPLICO culture emphasizing personal and professional growth.

• Commitment to equal opportunity employment.

• Centralized Service Center support, including clinical, legal, risk management, HR, training, accounting, and IT resources.