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 ensure compliance with regulatory requirements while maintaining accurate documentation and collaborating with internal departments.

Key responsibilities

• Evaluate clinically related denials and prepare clinical 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 compliance with submission timelines

Required qualifications

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