Clinical Appeals & Denial Nurse Specialist with expertise in medical coding, utilization review, and payer guidelines. Skilled in analyzing clinical documentation, drafting persuasive appeals, and resolving insurance denials to ensure fair reimbursement and patient advocacy. Strong communicator with proven ability to collaborate across interdisciplinary teams while maintaining compliance with healthcare regulations.
Job Responsibilities:
Denials and Appeals Management:
- Work denials and appeals timely, evaluating the denial reason including information from the payor and payor policies, reviewing the clinical documentation, assessing options and completing next steps
- Submit retro-authorizations in accordance with payor requirements in response to authorization denials
- Conducts medical necessity reviews, based on denial root cause, and prepares any required clinical documentation summaries to accompany appeals.
- Write and submit written appeals which include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language. Appeals are submitted timely and tracked through final outcome.
- Document all actions taken and follow-up timely as needed related to resolving denials and appeals with third-party payers in a timely manner
- Tracks the status and progress of denials and appeals
- Completes relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms
- Executes internal and external correspondence accurately, clearly, concisely, and professionally while following organizational regulations
- Effectively handles all communications, including telephone, electronic, and paper correspondence from payers and departments within the business office
Tracking, Reporting, and Trends:
- Maintains data on the types of claims denied and root causes of denials
- Identify denial patterns and escalate to management as appropriate with sufficient information for additional follow-up, and/or root cause resolution
- Collaborate with management to recommend process changes to address root cause of denials and overall improvement to reduce A/R
- Prepares, maintains, assists with, and submits reports as required
Compliance and Continuous Improvement:
- Collaborate with team members to continually improve services, and engage in process and quality improvement activities
- Identify system improvement opportunities and contribute to the testing of system modifications
- Conducts relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms
- Complies with state and federal regulations, accreditation/compliance requirements, and Huron's policies, including those regarding fraud and abuse, confidentiality, and HIPAA
- Maintains a thorough understanding of federal and state regulations, as well as specific payer requirements and explanations of benefits, in order to identify and report billing compliances issues and payer discrepancies
- Participates in ongoing professional development to enhance job knowledge and performance
- Reports all identified compliance risks to appropriate leadership
Qualifications:
Required Qualifications - (Non-Negotiables)
Clinical Appeals Experience:
- At least 1 year of clinical appeal writing experience.
- 3–5 years acute care (Med/Surg preferred); 2–3 years ICU.
- Education: BS in Nursing.
- Licensure: Active PHRN or USRN.
- Knowledge: InterQual/MCG guidelines, U.S. insurance regulations, hospital EMRs (Epic, Cerner, Meditech).
- Skills: Strong English communication (CEFR B2+), customer service.
Preferred:
- Education: Masters in business/healthcare or related.
- Certification: Case management/appeals/denials (ACMA).
- Software: Denials/appeals tracking tools, Microsoft Office suite
