Clinical Denials Specialist (On-Site)

NorthBay Health•Fairfield, CA

22d•$50 - $60•Onsite

About The Position

The Clinical Denials Specialist performs advanced clinical and revenue cycle functions related to payer denials, including medical necessity, prior authorization, referrals, notifications, non-coverage determinations, and other denial categories. The role reviews and analyzes denied claims; prepares and submits comprehensive appeals; and collaborates with physicians, Health Information Management, Case Management, Coding, Patient Financial Services, and other interdisciplinary teams to resolve denials, identify root causes and trends, and support denial prevention and revenue optimization. The specialist manages the appeal process from receipt and review through documentation, tracking, submission, and resolution with third-party payers. The position conducts detailed clinical and coding reviews, follows payer requirements and regulatory guidelines, and escalates complex cases as appropriate to maximize reimbursement and improve first-pass claim success. It also supports denial prevention through trend analysis, education, policy monitoring, operational recommendations, and reporting to Revenue Cycle leadership. This is an on-site position in Fairfield, California. Hours are based on business need and are mostly Monday through Friday, 8 a.m. to 5 p.m.

Requirements

Associate degree, 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 acute care hospital experience.
Ability to exercise mature, 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 in decision-making.
Ability to research, learn, and obtain knowledge relevant to the position.
Professional demeanor, team spirit, and ability to work collaboratively and effectively.
Adherence to established policies and procedures and attendance and punctuality standards.
Ability to perform job activities that may include walking, periods of sitting, keyboarding, and standing.

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, to determine an appropriate resolution strategy.
Review medical records, clinical documentation, coding, payer contracts and policies, CMS regulations, LCDs/NCDs, InterQual, MCG, and commercial payer guidelines to assess medical necessity, coding accuracy, appeal opportunities, and regulatory compliance.
Develop, prepare, and submit first-level and subsequent-level appeals supported by 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 supporting documentation, strengthen appeals, resolve denials, and improve reimbursement outcomes.
Review denied claims for coding accuracy, documentation completeness, and charge integrity, identifying opportunities for coding clarification, documentation improvement, charge capture enhancement, and revenue recovery before appeal submission.
Prioritize high-dollar, high-risk, and complex denials and perform 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 to physicians, coding professionals, CDI specialists, case management, utilization management, revenue cycle departments, and other clinical staff on payer requirements, documentation, coding, medical necessity, denial trends, and denial reduction opportunities.
Serve as a subject matter expert on payer medical necessity requirements, CMS regulations, Medicare Advantage and commercial payer policies, coding regulations, reimbursement methodologies, and industry best practices; monitor policy changes and communicate operational impacts.
Participate in payer discussions, peer-to-peer reviews, defense audits, external audits, RAC, Medicare Advantage and 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 to support decision-making and continuous improvement.
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.

Benefits

Medical, dental, and vision insurance, subject to eligibility.
Life, disability, and long-term care coverage.
Paid time off, including vacation, sick leave, holidays, and bereavement.
403(b) retirement plan with employer match.
Education reimbursement for eligible roles.
Professional development and training programs.
Employee Assistance Program.
Wellness programs.
Recognition programs.
Shift differentials.
Market-based compensation review and increases, subject to approval and organizational performance.