Clinical Denials Specialist - Ortigas

About the Job

The Clinical Denials Specialist plays a vital role in ensuring accurate reimbursement for healthcare services by reviewing denied claims, identifying denial reasons, and appealing claim denials.

This role collaborates closely with healthcare providers to gather the documentation and clinical evidence needed to build strong appeals, analyzes denial trends across the organization, and provides feedback to revenue cycle teams to help prevent future denials. Success requires a blend of clinical knowledge, coding and reimbursement expertise, and sharp analytical and writing skills.

Duties and Responsibilities

Denial Review & Appeals

• Knows, understands, incorporates, and demonstrates the Client Core Values in all interactions with team members, clients, and stakeholders.
• Reviews denied claims to identify denial reasons and discrepancies.
• Analyzes medical records, billing documents, and payer policies to prepare appeal arguments.
• Collaborates with healthcare providers to gather additional documentation and evidence for appeals.
• Develops effective, well-supported appeal strategies to overcome denial challenges.
• Documents appeal activities, correspondence, and outcomes for tracking and reporting purposes.

Denial Trend Analysis & Process Improvement

• Analyzes denial reasons and trends to identify opportunities for process improvement.
• Monitors denial trends and provides feedback to revenue cycle teams to prevent future denials.
• Participates in denial management meetings and contributes insights to improve denial prevention strategies.

Clinical & Regulatory Knowledge

• Applies knowledge of medical terminology, coding principles, and reimbursement guidelines to assess denial reasons and appeal opportunities.
• Stays updated on payer policies, regulations, and reimbursement guidelines relevant to claim denials.
• Adapts to changing payer policies, regulations, and reimbursement requirements.

Communication & Collaboration

• Communicates clearly and persuasively, both verbally and in writing, to collaborate with healthcare providers and present appeal arguments.
• Applies keen attention to detail to ensure accurate review and analysis of denied claims and medical records.
• Performs other duties as assigned.

Qualifications

Required

• Bachelor’s degree in Healthcare Administration, Nursing, Health Information Management, or a related field.
• Active USRN license with clinical denials or Clinical Documentation Improvement (CDI) credentialing.
• Minimum of 2-3 years of experience in healthcare revenue cycle management, medical billing, claims processing, or denial management.
• Strong problem-solving skills with the ability to develop effective appeal strategies.
• Completion of regulatory/mandatory certifications as required.
• Willingness and ability to travel to client or organizational sites as needed.

Preferred

• Certified Denials and Appeals Specialist (CDAS) or equivalent denial management credential.
• Experience with EHR systems, such as Epic, and payer denial management portals.