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Clinical Denials and Appeals Specialist
Affordable Housing Trust for Columbus and Franklin CountyClinical Denials and Appeals Specialist reviewing complex payer denials for UASI healthcare clients. Involves appeal generation, strategy, and overturn clinical denials.
About the role
Key responsibilities & impact- Generate comprehensive first-level, second-level, and escalated appeal letters for denied claims.
- Develop compelling clinical arguments using medical records, physician documentation, industry standards, and payer policies.
- Create appeal packages with all required supporting documentation and submit within payer timelines.
- Track appeal status, deadlines, and outcomes to ensure timely follow-up.
- Review and revise appeal content to improve quality, consistency, and overturn success rates.
- Review and assess denials related to:
- Medical necessity
- Level of care
- Clinical validation
- Authorization issues
- Audit findings
- Conduct detailed chart reviews to validate payer rationale and determine appeal viability.
- Analyze denial trends and identify opportunities for overturn and prevention.
- Apply CMS regulations, Medicare guidelines, LCDs, NCDs, payer policies, and industry guidance to support appeal arguments.
- Maintain current knowledge of ICD-10-CM/PCS coding requirements, DRG methodologies, and reimbursement regulations.
- Monitor payer updates and regulatory changes impacting denials and appeals.
- Assist in developing appeal templates, reference materials, and best practices.
- Provide recommendations to improve appeal effectiveness and reduce future denials.
- Contribute to denial prevention initiatives through trend analysis and education.
- Partner with physicians, CDI specialists, case management, utilization review, coding, and HIM teams to strengthen appeal outcomes.
Requirements
What you’ll need- Active Registered Nurse (RN) license required; BSN preferred.
- Minimum 5 years of clinical nursing experience.
- Minimum 3–5 years of denials management & appeals generation.
- Demonstrated success generating and overturning clinical denials.
- Strong knowledge of:
- Medical necessity criteria
- DRG reimbursement methodology
- ICD-10-CM/PCS
- CPT/HCPCS
- Medicare and Medicaid regulations
- Commercial payer policies
- Experience using InterQual and/or MCG criteria.
- Strong proficiency in Microsoft Word and healthcare documentation systems.
- Exceptional written communication and persuasive writing skills.
Benefits
Comp & perks- Medical, dental, vision and life insurance
- short/long-term disability
- 401(K) and referral bonuses
- Training opportunities and reimbursement for professional certifications
- UASI's unique approach to employee appreciation which include birthday recognition, holiday gift selections, performance awards, and years of service awards
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
Clinical Denials ManagementAppeal Letter GenerationChart ReviewDenial Trend AnalysisDRG Reimbursement MethodologyCPT/HCPCS KnowledgeCMS RegulationsMedicare GuidelinesPayer PoliciesInterQual/MCG Criteria
Soft Skills
Exceptional Written CommunicationPersuasive WritingCollaborationAttention to DetailAnalytical Thinking
Certifications
BSN Preferred