01Overview
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.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.Key ResponsibilitiesAppeal Development and SubmissionGenerate comprehensive first-level, second-level, and escalated appeal letters for denied claims.Develop compelling clinical arguments using medical records, physician documentation, industry standards, and payer policies.Create appeal packages with all required supporting documentation and submit within payer timelines.Track appeal status, deadlines, and outcomes to ensure timely follow-up.Review and revise appeal content to improve quality, consistency, and overturn success rates.Clinical Denial AnalysisReview and assess denials related to:Medical necessityLevel of careClinical validationAuthorization issuesAudit findingsConduct detailed chart reviews to validate payer rationale and determine appeal viability.Analyze denial trends and identify opportunities for overturn and prevention.Regulatory and Clinical ResearchApply CMS regulations, Medicare guidelines, LCDs, NCDs, payer policies, and industry guidance to support appeal arguments.Maintain current knowledge of ICD-10-CM/PCS coding requirements, DRG methodologies, and reimbursement regulations.Monitor payer updates and regulatory changes impacting denials and appeals.Collaboration and Process ImprovementAssist in developing appeal templates, reference materials, and best practices.Provide recommendations to improve appeal effectiveness and reduce future denials.Contribute to denial prevention initiatives through trend analysis and education.As needed, Partner with physicians, CDI specialists, case management, utilization review, coding, and HIM teams to strengthen appeal outcomes.Required QualificationsActive Registered Nurse (RN) license required; BSN preferred.Minimum 5 years of clinical nursing experience.Minimum 35 years of denials management & appeals generation.Demonstrated success generating and overturning clinical denials.Strong knowledge of:Medical necessity criteriaDRG reimbursement methodologyICD-10-CM/PCSCPT/HCPCSMedicare and Medicaid regulationsCommercial payer policiesExperience using InterQual and/or MCG criteria.Strong proficiency in Microsoft Word and healthcare documentation systems.Exceptional written communication and persuasive writing skills.Preferred QualificationsBackground in critical care, emergency department, operating room, case management, or utilization review.CDI (Clinical Documentation Integrity) experience.Familiarity with Epic.Experience analyzing denial data and reporting trendsWhy UASI UASI is the employer of choice due to our outstanding reputation for excellence within the industry and for our comprehensive benefit package which includes:Medical, dental, vision and life insurance, short/long-term disability, 401(K) and referral bonusesTraining opportunities and reimbursement for professional certificationsUASI's unique approach to employee appreciation which include birthday recognition, holiday gift selections, performance awards, and years of service awardsOriginally posted on Himalayas
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