Georgia Licensed Clinical Denial Specialist

Job Summary

To support effective care coordination, the full-time Georgia Licensed Clinical Denial Specialist will process, track, and appeal clinical denials while collaborating on Utilization Management data methodologies in a remote setting.

Key responsibilities

• Process and appeal clinical denials, ensuring compliance with industry guidelines
• Support the design and implementation of data collection methodologies for Utilization Management
• Analyze data to identify trends and develop actionable plans in collaboration with the care team

Required qualifications

• Graduate of an accredited school of nursing with strong clinical case management experience
• Three years of experience in Utilization Management/Case Management or related field
• Knowledge of coding, billing, audit, and reimbursement payer methodologies and guidelines
• Experience in data collection, interpretation, and presentation to medical staff
• Ability to communicate effectively with various stakeholders, including managed care companies