Clinical Denial Specialist - FT - Day - Revenue Integrity & Denials Mgmt Lawrenceville NJ

Capital Health (US)•Pike, NY

13d•$20 - $26

About The Position

The Clinical Denial Specialist is responsible for administrative management, tracking, and coordination of inpatient clinical denials, including patient status determinations, medical necessity denials, and readmission-related denials. The role ensures cases are triaged, routed, documented, tracked, and prepared for appeal in accordance with payer requirements, partnering with clinical and operational resources to support timely resolution and denial prevention. The position works with Clinical Appeals RNs, CDI, Utilization Review, Case Management, Physician Advisors, and clinical leadership. It identifies recurring denial trends and supports prevention initiatives. The position is based in Lawrenceville, New Jersey, and is scheduled for 40 hours per week with an eight-hour usual workday.

Requirements

High school diploma or equivalent.
Three years of hospital billing, denials management, utilization review support, or related revenue cycle experience.
Working knowledge of inpatient clinical denial categories, including medical necessity, patient status, and readmissions.
Familiarity with utilization review processes and clinical documentation workflows.
Ability to perform detailed tracking, documentation, and inventory management across multiple appeal levels.
Strong organizational skills and attention to detail.
Ability to identify root causes and recurring denial drivers.
Strong written communication skills for documentation and internal coordination.
Proficiency with hospital billing systems, EMR navigation, payer portals, and Microsoft Office applications, including Excel.
Ability to meet deadlines, exercise good judgment, and remain metric-driven and results-oriented.

Nice To Haves

Associate or bachelor’s degree in a healthcare- or business-related field.
Experience working inpatient clinical denials, patient status determinations, or medical necessity denials.

Responsibilities

Review and triage inpatient clinical denials, including medical necessity, patient status, and readmission-related denials.
Route cases to appropriate clinical resources based on denial type and appeal viability.
Maintain accurate denial inventories, including deadlines, appeal levels, documentation status, and outcomes.
Coordinate medical record requests, appeal packet preparation logistics, and submission tracking.
Ensure compliance with payer requirements, timelines, and documentation standards.
Perform payer follow-up, including portal research and telephone outreach as needed.
Document clear, concise, and accurate notes in the hospital billing system.
Identify recurring denial trends by payer, service line, unit, or provider and escalate findings to leadership.
Support denial prevention initiatives in partnership with Utilization Review, Case Management, CDI, and clinical leadership.
Maintain current knowledge of payer inpatient denial practices and appeal processes.
Perform other duties as assigned and adapt to changing departmental demands.