Clinical Denial Specialist

Guidehouse•Ada, OK

1d•$40,000 - $66,000

About The Position

Receive, triage, and prioritize denied hospital claims based on timely filing requirements, financial impact, and payer response deadlines. Conduct root cause analysis to identify clinical, documentation, authorization, or payer‑related reasons for denial. Coordinate clinical denial cases with nurse reviewers, coding, utilization management, and revenue cycle teams to determine appeal viability. Assemble and submit complete appeal packets, ensuring inclusion of appropriate clinical documentation and payer-specific requirements. Submit appeals via payer portals, secure fax, or mail, and confirm receipt to ensure timely adjudication. Perform systematic appeal follow‑up at defined intervals until final claim resolution is achieved. Track denial and appeal activity, maintaining accurate documentation within hospital and payer systems. Identify denial trends and recurring issues and communicate findings to leadership to support process improvement initiatives. Adhere to all hospital policies, payer guidelines, and regulatory requirements related to claims and appeals processing.

Requirements

Associate or bachelor’s degree in healthcare administration, medical assistant, health information management, or a related field.
Prior experience in hospital revenue cycle, clinical denials, appeals, utilization management, or medical claims processing.
Strong understanding of payer denial codes, appeal workflows, and hospital billing processes.

Nice To Haves

Clinical background or experience working directly with nursing or utilization management teams.
Experience with inpatient hospital claims, DRG‑based reimbursement, and payer portals.
Excellent organizational, analytical, and written communication skills.
Ability to manage multiple accounts simultaneously while meeting strict deadlines
Strong understanding of payer denial codes, appeal workflows, and hospital billing processes.

Responsibilities

Receive, triage, and prioritize denied hospital claims based on timely filing requirements, financial impact, and payer response deadlines.
Conduct root cause analysis to identify clinical, documentation, authorization, or payer‑related reasons for denial.
Coordinate clinical denial cases with nurse reviewers, coding, utilization management, and revenue cycle teams to determine appeal viability.
Assemble and submit complete appeal packets, ensuring inclusion of appropriate clinical documentation and payer-specific requirements.
Submit appeals via payer portals, secure fax, or mail, and confirm receipt to ensure timely adjudication.
Perform systematic appeal follow‑up at defined intervals until final claim resolution is achieved.
Track denial and appeal activity, maintaining accurate documentation within hospital and payer systems.
Identify denial trends and recurring issues and communicate findings to leadership to support process improvement initiatives.
Adhere to all hospital policies, payer guidelines, and regulatory requirements related to claims and appeals processing.

Benefits

Medical, Rx, Dental & Vision Insurance
Personal and Family Sick Time & Company Paid Holidays
Position may be eligible for a discretionary variable incentive bonus
Parental Leave
401(k) Retirement Plan
Basic Life & Supplemental Life
Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
Short-Term & Long-Term Disability
Tuition Reimbursement, Personal Development & Learning Opportunities
Skills Development & Certifications
Employee Referral Program
Corporate Sponsored Events & Community Outreach
Emergency Back-Up Childcare Program