Clinical Denials and Appeals Specialist

Role Overview

• 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

• 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

• 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