State Licensed Clinical Denials Director

Job Summary

A company is looking for a Sr. Director, Clinical Denials, who will serve as the primary clinical authority for denial prevention and appeal strategy.

Key Responsibilities

• Serve as the lead clinical subject matter expert on clinical denials management and prevention
• Partner with provider clients to design and implement best practices for denial prevention and appeal workflows
• Conduct complex clinical case reviews for DRG validation and analyze denial trends to provide actionable insights

Requirements and Qualifications

• Bachelor's Degree
• Registered Nurse (RN) with at least 10 years of acute care clinical experience
• 5+ years of experience in clinical denials management or revenue integrity
• Strong knowledge of MS-DRG and APR-DRG methodologies
• Proficiency with CMS rules, payer contracts, and medical necessity guidelines