California Licensed Clinical Denials Specialist

Job Summary

As a full-time remote California Licensed Clinical Denials Specialist, the Senior Clinical Denials Appeal Specialist will evaluate clinically related denials, prepare and submit appeal arguments, and collaborate with internal departments to resolve documentation issues while ensuring compliance with regulatory requirements.

Key responsibilities

• Evaluate clinically related denials and prepare compliant appeal submissions to various payers
• Conduct thorough analyses of assigned denials, assessing clinical validity and appropriateness of services
• Maintain detailed documentation of appeal activities and ensure timely submission within required timelines

Required qualifications

• Bachelor's Degree (BSN) preferred; Diploma or Associate's Degree in Nursing accepted with significant experience
• Minimum of five years in nursing, including two years as a Utilization Management Nurse in an acute care setting
• Experience with 2 Midnight, Milliman, and InterQual Guidelines required
• Two years of experience in denial prevention, denial recovery, or clinical appeals within a healthcare setting
• Valid California Registered Nurse license required upon hire