Specialist, Clinical Appeals

Clinical Denial Review and Analysis:Perform comprehensive reviews of denied claims, focusing on clinical issues such as medical necessity, level of care, non-covered services, and authorization-related denials.Conduct thorough analysis of patient medical records, payer medical policies, and relevant medical necessity criteria (e.g., InterQual, Milliman) to build a robust clinical case for appeal.Identify gaps in clinical documentation and collaborate with other team members to gather the necessary supporting evidence for a successful appeal.Appeal Generation and Submission:Independently write professional, persuasive appeal letters that present a compelling clinical argument for payment.Leverage generative AI tools to assist in drafting initial appeal letters, increasing efficiency and allowing focus on the most complex cases.Ensure all appeals are submitted accurately, within payer-specific timelines, and tracked through to final resolution in the Pulse platform.Collaboration and Process Improvement:Work closely with the Payer Contract Specialist, Certified Coders, and Revenue Recovery Specialists to ensure a holistic and coordinated approach to each appeal.Identify and report emerging denial trends to team leadership to support root cause analysis and the development of denial prevention strategies.Assist in creating and maintaining standardized appeal letter templates for various denial types and payers to improve team efficiency.KNOWLEDGE, SKILLS, AND ABILITIES: Strong clinical acumen with the ability to critically analyze medical records and justify the medical necessity of services rendered.Exceptional written communication skills, with the ability to craft clear, concise, and persuasive arguments.Technologically proficient and comfortable learning and mastering new software; experience with EHR/EMR systems is essential.Comfortable navigating and troubleshooting various applications, including Microsoft Office Suite, data management systems, and virtual collaboration tools.Highly organized, self-motivated, and able to work independently to manage a caseload and meet deadlines.Familiarity with medical billing, coding principles (ICD-10, CPT), and payer reimbursement methodologies.WORK EXPERIENCE, EDUCATION AND CERTIFICATIONS: Active and unrestricted Registered Nurse (RN) license.Bachelor of Science in Nursing (BSN) preferred.Previous experience in denial management or clinical appeals role.Minimum of 2-3 years of clinical experience in a hospital or healthcare setting. Experience in Case Management, Utilization Review, or Clinical Documentation Improvement (CDI) is highly desirable.Technologically proficient and comfortable learning and mastering new software; experience with EHR/EMR systems is essential.WORKING CONDITIONS AND PHYSICAL REQUIREMENTS: 100% RemoteReliable high-speed internet connection is required for all remote/hybrid positions.Must have access to stable Wi-Fi with sufficient bandwidth to support video conferencing, cloud-based tools, and other online work-related activities.A HIPAA-compliant work environment is required, including a secure workspace free from unauthorized access or interruptions, no use of public Wi-Fi unless connected through a secure company-provided VPN, and compliance with all applicable HIPAA privacy and security regulations.