Specialist, Clinical Appeals

• Clinical Denial Review and Analysis:
  • Perform comprehensive reviews of denied claims, focusing on clinical issues such as medical necessity, level of care, non-covered services, and authorization-related denials.
  • Conduct thorough analysis of patient medical records, payer medical policies, and relevant medical necessity criteria (e.g., InterQual, Milliman) to build a robust clinical case for appeal.
  • Identify gaps in clinical documentation and collaborate with other team members to gather the necessary supporting evidence for a successful appeal.
• Appeal Generation and Submission:
  • Independently write professional, persuasive appeal letters that present a compelling clinical argument for payment.
  • Leverage generative AI tools to assist in drafting initial appeal letters, increasing efficiency and allowing focus on the most complex cases.
  • Ensure all appeals are submitted accurately, within payer-specific timelines, and tracked through to final resolution in the Pulse platform.
• Collaboration and Process Improvement:
  • Work closely with the Payer Contract Specialist, Certified Coders, and Revenue Recovery Specialists to ensure a holistic and coordinated approach to each appeal.
  • Identify and report emerging denial trends to team leadership to support root cause analysis and the development of denial prevention strategies.
  • Assist in creating and maintaining standardized appeal letter templates for various denial types and payers to improve team efficiency.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Strong clinical acumen with the ability to critically analyze medical records and justify the medical necessity of services rendered.
• Exceptional written communication skills, with the ability to craft clear, concise, and persuasive arguments.
• Technologically proficient and comfortable learning and mastering new software; experience with EHR/EMR systems is essential.
• Comfortable navigating and troubleshooting various applications, including Microsoft Office Suite, data management systems, and virtual collaboration tools.
• Highly organized, self-motivated, and able to work independently to manage a caseload and meet deadlines.
• Familiarity with medical billing, coding principles (ICD-10, CPT), and payer reimbursement methodologies.

WORK EXPERIENCE, EDUCATION AND CERTIFICATIONS:

Active and unrestricted Registered Nurse (RN) license.

Bachelor of Science in Nursing (BSN) preferred.

Previous experience in denial management or clinical appeals role.

Minimum of 2-3 years of clinical experience in a hospital or healthcare setting. Experience in Case Management, Utilization Review, or Clinical Documentation Improvement (CDI) is highly desirable.

Technologically proficient and comfortable learning and mastering new software; experience with EHR/EMR systems is essential.

WORKING CONDITIONS AND PHYSICAL REQUIREMENTS:

• 100% Remote
• Reliable high-speed internet connection is required for all remote/hybrid positions.
• Must have access to stable Wi-Fi with sufficient bandwidth to support video conferencing, cloud-based tools, and other online work-related activities.
• A HIPAA-compliant work environment is required, including a secure workspace free from unauthorized access or interruptions, no use of public Wi-Fi unless connected through a secure company-provided VPN, and compliance with all applicable HIPAA privacy and security regulations.