Clinical Denials and Appeals Specialist

3 weeks, 3 days ago
Full-time
Senior
Technical Writing and Documentation
UASI Solutions

UASI Solutions

UASI Solutions is a top provider of revenue cycle solutions for healthcare facilities, offering coding services and Health Information Management solutions with a focus on accuracy and efficiency.

Diversified Financial Services
251-1K
Founded 1984

Description

  • Generate first-level, second-level, and escalated appeal letters for denied claims.
  • Develop clinical arguments using medical records, physician documentation, industry standards, and payer policies.
  • Create complete appeal packages with supporting documentation and submit them 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.
  • Analyze denials related to medical necessity, level of care, clinical validation, authorization issues, and audit findings.
  • Conduct detailed chart reviews to validate payer rationale and determine whether an appeal is viable.
  • Analyze denial trends to identify opportunities for overturn and future denial prevention.
  • Apply CMS regulations, Medicare guidelines, LCDs, NCDs, payer policies, and industry guidance to support appeals.
  • 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 and appeals generation experience.
  • 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, and 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.
  • Background in critical care, emergency department, operating room, case management, or utilization review preferred.
  • CDI experience and familiarity with Epic preferred.

Benefits

  • Medical, dental, vision, and life insurance.
  • Short- and long-term disability coverage.
  • 401(k) retirement plan.
  • Referral bonuses.
  • Training opportunities and reimbursement for professional certifications.
  • Birthday recognition, holiday gift selections, performance awards, and years-of-service awards.

Interested in this position?

Apply directly on the company website

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