Clinical Denials & Appeals Specialist

JOB TITLE
Specialist - Clinical Review

POSITION SUMMARY
The Specialist – Clinical Review is responsible for reviewing, analyzing, and appealing denied claims for Ambulatory Surgery Center (ASC) services. This role focuses on denials related to medical necessity, authorization/pre-certification, level of care, medical documentation, and payer policy determinations. The Specialist – Clinical Review collaborates with physicians, coding, billing, and revenue cycle teams to develop compelling clinical appeal arguments that maximize reimbursement and reduce avoidable denials.

ESSENTIAL FUNCTIONS

Denial Review & Appeals

• Review denied ASC claims to determine root cause and appeal opportunities.
• Analyze payer denial rationale related to:
  • Medical necessity
  • Prior authorization/pre-certification
  • Experimental/investigational services
  • Medical documentation deficiencies
  • Level of care determinations
  • Bundling and reimbursement disputes
• Conduct comprehensive clinical reviews of patient records, operative reports, physician documentation, and supporting medical records.
• Prepare and submit quality clinical appeal letters with supporting documentation.
• Manage first-level, second-level, reconsideration, and external review appeals.
• Track appeal status and ensure timely follow-up within payer filing deadlines.
• Escalate complex denial cases to leadership when appropriate.

Clinical Documentation Review

• Evaluate medical records for completeness and compliance with payer requirements.
• Identify missing clinical documentation that may impact reimbursement.
• Collaborate with physicians and clinical staff to obtain additional supporting documentation.
• Ensure appeal packets include all required clinical evidence and supporting records.

Revenue Recovery & Denial Prevention

• Identify denial trends and recurring payer issues.
• Recommend corrective actions to reduce future denials.
• Partner with Authorization, Coding, Billing, and Clinical Operations teams to improve front-end processes.
• Participate in denial management meetings and revenue recovery initiatives.
• Support revenue integrity efforts through ongoing analysis of payer policies and reimbursement guidelines.

Regulatory & Compliance

• Maintain compliance with Medicare, Medicaid, commercial payer, and regulatory requirements.
• Stay current on payer medical necessity criteria and utilization management guidelines.
• Ensure appeals are submitted in accordance with payer contractual requirements and appeal time frames.
• Always maintain confidentiality and HIPAA compliance.

Reporting & Performance Management

• Document actions and appeal outcomes within the practice management system.
• Track appeal success rates, overturn rates, and recovered revenue.
• Assist with preparation of denial management reports and key performance indicators (KPIs).
• Monitor aging of denied accounts and prioritize high-dollar opportunities.

Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day.

NOTE:

The essential functions are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties. Specific tasks or responsibilities will be documented as outlined by the incumbent's immediate manager.

MINIMUM QUALIFICATIONS

• Associate’s Degree or Diploma in Nursing, or higher, required. Must possess a current, valid RN license in state of practice, temporary RN license in state of practice, or compact RN licensure for current state of practice.

• Minimum 2 years of experience reviewing and appealing medical necessity denials.

• Minimum 3…