Clinical Denials and Appeals Specialist

Responsibilities

• Generate comprehensive first-level, second-level, and escalated appeal letters for denied claims
• Develop compelling clinical arguments using medical records, physician documentation, and payer policies
• Create appeal packages with all required supporting documentation and submit within payer timelines
• Review and assess denials related to medical necessity, level of care, clinical validation, and authorization issues
• Conduct detailed chart reviews to validate payer rationale and determine appeal viability
• Apply CMS regulations, Medicare guidelines, LCDs, NCDs, and payer policies to support arguments
• Partner with physicians, CDI specialists, and utilization review teams to strengthen outcomes

Requirements

• Active Registered Nurse (RN) license
• Minimum 5 years of clinical nursing experience
• Minimum 3–5 years of denials management and appeals generation experience
• Demonstrated success overturning clinical denials
• Strong knowledge of medical necessity criteria, DRG reimbursement, ICD-10-CM/PCS, and CPT/HCPCS
• Experience using InterQual and/or MCG criteria
• Exceptional written communication and persuasive writing skills

Preferred Qualifications

• BSN degree
• Background in critical care, emergency department, operating room, case management, or utilization review
• CDI (Clinical Documentation Integrity) experience
• Familiarity with Epic
• Experience analyzing denial data and reporting trends

Benefits

• Medical, dental, vision, and life insurance
• Short/long-term disability
• 401(K) and referral bonuses
• Training opportunities and professional certification reimbursement
• Employee appreciation programs including performance and service awards

About the Company

UASI is an industry leader known for excellence in healthcare management and a commitment to employee appreciation and professional growth.