State Licensed Clinical Denial Specialist

Job Summary

To support effective denial management, the full-time salaried State Licensed Clinical Denial Specialist will manage the review and appeal process for hospital-based clinical, coding, and diagnosis-related grouping denials while working remotely.

Key responsibilities

• Conduct comprehensive reviews of patient medical records to validate clinical relevance and assess DRG accuracy
• Prepare and submit detailed clinical appeals, negotiating with external auditors as necessary
• Collaborate with clinical, coding, and revenue cycle teams to enhance compliance and documentation quality

Required qualifications

• Associate or Bachelor's degree in healthcare administration, Nursing, Health Information Management, or a related field
• Five years of experience in hospital billing, acute care settings, CDI, inpatient coding, or revenue cycle (or three years with a Bachelor's degree)
• Current Registered Nurse or Licensed Practical Nurse license, or relevant certification (e.g., RHIT, RHIA, CCDS, CDIP, CCS, CIC)
• Strong knowledge of CMS guidelines, coding rules, and clinical standards
• Experience with hospital appeals/denials and compliance processes is preferred