State Licensed Clinical Denial Specialist

Job Summary

To support effective denial management, the full-time salaried State Licensed Clinical Denial Specialist will conduct comprehensive reviews of patient medical records, prepare clinical appeals, and collaborate with various stakeholders to enhance compliance and documentation quality in a remote work environment.

Key responsibilities

• Manage the timely review and response to hospital billing audits, ensuring compliance with CMS guidelines and coding rules
• Prepare and submit detailed clinical appeals for insurance denials while negotiating with external auditors as needed
• Collaborate with clinical, coding, and revenue cycle teams to develop educational materials and improve processes related to denial management

Required qualifications

• Associate degree in healthcare administration, Nursing, Health Information Management, or related field with five years of relevant experience, or a Bachelor's degree with three years of experience
• Current state or multi-state Registered Nurse or Licensed Practical Nurse license, or relevant certifications such as RHIT, RHIA, CCDS, CDIP, CCS, or CIC
• Experience in hospital billing, acute care setting, CDI, inpatient coding, or revenue cycle
• Strong technology skills, including proficiency in Epic, Excel, and DRG groupers
• Ability to work independently with minimal supervision while maintaining current clinical and coding knowledge