Clinical Denials and Appeals Specialist

About this role

We are seeking an experienced Clinical Denials and Appeals Specialist to join our Denials Management team. This role is responsible for reviewing complex payer denials and developing high-quality, evidence-based appeal letters that maximize reimbursement recovery for our healthcare clients. The ideal candidate is a strong clinical reviewer and exceptional writer who can analyze medical records, identify weaknesses in payer determinations, and craft persuasive appeals supported by clinical documentation, regulatory guidance, and payer-specific requirements.

The majority of this role is dedicated to appeal generation, appeal strategy, and overturning clinical denials. Key Responsibilities Appeal Development and Submission Generate comprehensive first-level, second-level, and escalated appeal letters for denied claims. Develop compelling clinical arguments using medical records, physician documentation, industry standards, and payer policies. Create appeal packages with all required supporting documentation and submit 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. Clinical Denial Analysis Review and assess denials related to: Medical necessity Level of care Clinical validation Authorization issues Audit findings Conduct detailed chart reviews to validate payer rationale and determine appeal viability. Analyze denial trends and identify opportunities for overturn and prevention.

Regulatory and Clinical Research Apply CMS regulations, Medicare guidelines, LCDs, NCDs, payer policies, and industry guidance to support appeal arguments. Maintain current knowledge of ICD-10-CM/PCS coding requirements, DRG methodologies, and reimbursement regulations. Monitor payer updates and regulatory changes impacting denials and appeals. Collaboration and Process Improvement Assist in developing appeal templates, reference materials, and best practices.

Provide recommendations to improve appeal effectiveness and reduce future denials. Contribute to denial prevention initiatives through trend analysis and education. As needed, Partner with physicians, CDI specialists, case management, utilization review, coding, and HIM teams to strengthen appeal outcomes. Required Qualifications Active Registered Nurse (RN) license required; BSN preferred. Minimum 5 years of clinical nursing experience.