State Licensed Clinical Denial Specialist

Job Summary

Managing denial appeals and ensuring compliance, the full-time State Licensed Clinical Denial Specialist will conduct comprehensive reviews of patient medical records, validate clinical relevance, and negotiate with external auditors in a remote setting.

Key responsibilities

• Manage timely reviews and responses to hospital billing audits and appeals
• Prepare and submit detailed clinical appeals while collaborating with clinical and coding teams
• Evaluate patient medical records to ensure accuracy in documentation and billing

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-issued Registered Nurse or Licensed Practical Nurse license, or relevant certification (RHIT, RHIA, CCDS, CDIP, CCS, CIC)
• Experience in hospital billing, acute care settings, CDI, inpatient coding, or revenue cycle
• Strong knowledge of CMS guidelines, coding rules, and clinical standards
• Ability to work independently with minimal supervision while maintaining current clinical and coding knowledge