Director, Clinical Denials

Healthrise

Director of Clinical Denials providing leadership over clinical denial management with a focus on appeals performance. Building a high-performing team and shaping strategies for multi-payer organizations.

Posted 6/2/2026full-time🇺🇸 United StatesLeadWebsite

Tech Stack

Tools & technologies

Oracle

About the role

Key responsibilities & impact

Provides specialized operational and strategic leadership over the full scope of the organization's clinical denial management function.
Responsible for driving clinical appeal performance across medical necessity, level-of-care, length-of-stay, DRG clinical validation, and experimental or non-covered service denials for all payer types and service lines.
Owns the clinical denial function end to end, from the quality of individual appeal letters to the design of appeal workflows.
Develops clinical appeal writers and manages cross-functional partnerships that address root causes before denials occur.
Engages physician advisors, payer medical directors, and executive stakeholders with confidence.
Builds a high-performing clinical appeals team and shapes the clinical denial strategy for a complex, multi-payer organization.

Requirements

What you’ll need

Bachelor's degree in Nursing, Health Information Management, Healthcare Administration, or a related clinical or health sciences field.
Active Registered Nurse (RN) licensure required; other advanced clinical licensure will be considered in combination with substantial clinical denial leadership experience.
Minimum 7 years of experience in healthcare revenue cycle with a primary focus on clinical denials management, utilization review, or case management, including at least 3 years in a management or director-level role.
Demonstrated track record of leading clinical denial teams and driving measurable improvement in appeal overturn rates and clinical denial write-off reduction across multiple payer types.
Expert-level knowledge of clinical criteria tools including InterQual and MCG/Milliman Care Guidelines, and the ability to apply them to complex clinical appeal arguments.
Deep understanding of Medicare, Medicaid, Medicare Advantage, and commercial payer medical necessity standards, coverage policies, and managed care authorization processes.
Working knowledge of ICD-10-CM/PCS diagnosis and procedure coding concepts, MS-DRG and APR-DRG methodology, and DRG clinical validation as they relate to clinical denial rationale.
Experience managing physician advisor programs and peer-to-peer review workflows for concurrent and retrospective clinical denials.
Proficiency with major EHR platforms (Epic, Cerner/Oracle Health, or equivalent) and revenue cycle denial management systems.
Completion of regulatory/mandatory certifications as required.
Willingness and ability to travel to client or organizational sites as needed.

Benefits

Comp & perks

Health insurance
401(k) matching
Flexible work hours
Paid time off
Professional development opportunities

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

clinical denial managementutilization reviewcase managementclinical criteria toolsInterQualMCG/Milliman Care GuidelinesICD-10-CM/PCS codingMS-DRG methodologyAPR-DRG methodologyclinical appeal arguments

Soft Skills

leadershipstrategic thinkingcommunicationcross-functional collaborationteam buildingproblem-solvingstakeholder engagementconfidenceperformance managementmentorship

Certifications

Registered Nurse (RN) licensure