Clinical Denials Specialist (On-Site)

NorthBay Healthcare Corporation•Fairfield, CA

21d•Onsite

About The Position

The Clinical Denials Specialist performs advanced clinical and revenue cycle work related to payer denials, including medical necessity, prior authorization, referrals, notifications, non-coverage determinations, and other assigned denial categories. The role reviews denied claims, prepares and submits appeals, and collaborates with physicians and interdisciplinary teams to resolve denials, identify root causes and trends, support prevention initiatives, and optimize revenue. The position is on-site in Fairfield, California. The specialist manages appeals from receipt through resolution, conducting detailed clinical and coding reviews and ensuring compliance with payer requirements and regulatory guidelines. The role prioritizes complex and high-impact cases, escalates them as appropriate, and supports reimbursement recovery and improved first-pass claim success. It also tracks and analyzes denial and appeal performance, reports findings to Revenue Cycle leadership, and contributes to continuous improvement.

Requirements

Associate degree required, or an equivalent combination of education and experience totaling four years.
Clinical license or certification required.
CCS, RHIT, or CPC certification required.
At least three years of experience in an acute care hospital.
Ability to exercise mature and independent judgment and investigate, analyze, and resolve issues at a high level.
Excellent communication, organizational, and problem-solving skills; strong analytical, research, and report-writing skills.
Knowledge of federal, state, and private agency review requirements and regulations.
Competence with Microsoft Office programs, including Outlook, Word, and Excel.
Ability to use critical thinking and sound clinical judgment and assessment skills for decision-making.
Demonstrates NorthBay Health True North values: Nurture/Care, Own It, Respect Relationships, Build Trust, and Hardwire Excellence.
Willingness to research, learn, and obtain knowledge needed to perform the position.
Courteous and professional demeanor, team spirit, and ability to work collaboratively and effectively.
Adherence to established policies and procedures and expected standards for attendance and punctuality.

Nice To Haves

Bachelor’s degree preferred.

Responsibilities

Review and analyze payer denials, including medical necessity, level of care, prior authorization, referrals, notifications, DRG validation, coding, documentation, and non-coverage determinations, and determine resolution strategies.
Review medical records, clinical documentation, coding, payer contracts and policies, CMS regulations, LCD/NCDs, InterQual®, MCG, and commercial payer guidelines for medical necessity, coding accuracy, appeal opportunities, and regulatory compliance.
Develop, prepare, and submit first-level and subsequent-level appeals using clinical documentation, coding guidelines, payer policies, regulatory requirements, and evidence-based literature.
Determine appeal strategies and coordinate escalation to second-level appeals, arbitration, external review, peer-to-peer discussions, and Physician Advisor review as appropriate.
Collaborate with physicians, Physician Advisors, Coding, CDI, HIM, Case Management, Utilization Management, Revenue Integrity, Patient Financial Services, and other departments to obtain documentation, strengthen appeals, resolve denials, and improve reimbursement outcomes.
Review denied claims for coding accuracy, documentation completeness, and charge integrity; identify opportunities for coding clarification, documentation improvement, charge capture, and revenue recovery before appeal submission.
Prioritize high-dollar, high-risk, and complex denials; conduct financial impact analyses to identify recovery opportunities and revenue leakage.
Analyze denial trends and root causes related to documentation, coding, registration, authorization, utilization management, clinical workflows, and operational processes; collaborate with operational leaders on corrective actions and prevention strategies.
Develop and deliver education on payer requirements, documentation standards, coding guidelines, medical necessity criteria, denial trends, and specialty-specific opportunities to reduce denials.
Serve as a subject matter expert on payer medical necessity requirements, CMS and Medicare Advantage policies, commercial payer policies, coding regulations, reimbursement methodologies, and industry best practices.
Monitor regulatory and payer policy changes and communicate their operational impacts to leadership and affected departments.
Participate in payer discussions, peer-to-peer reviews, defense and external audits, RAC and Medicare Advantage audits, commercial payer audits, DRG validation audits, and other payer review activities.
Partner with Revenue Integrity and operational departments to identify reimbursement opportunities, improve charge capture, optimize workflows, and implement initiatives to reduce avoidable denials and improve financial performance.
Track denial inventory, appeal outcomes, overturn rates, financial recoveries, payer performance, denial trends, and key performance indicators using reporting and analytics tools.
Develop dashboards and present findings and recommendations to Revenue Cycle leadership.
Maintain complete and accurate documentation of appeal activity, payer communications, decisions, supporting evidence, and related records in accordance with organizational policies and regulatory requirements.
Perform other duties as assigned.