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
• Conduct medical necessity reviews, based on denial root cause, and prepare any required clinical documentation summaries to accompany appeals.
• W...