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

Capital Health (US)•Pike, NY

1d•Onsite

About The Position

Responsible for administrative management, tracking, and coordination of outpatient clinical denials, including medical policy denials, experimental or investigational determinations, and other payer clinical criteria denials. Ensures outpatient clinical denial cases are properly triaged, routed, documented, tracked, and prepared for appeal in accordance with payer requirements, while partnering with clinical and operational resources to support timely resolution and denial prevention.

Requirements

High school diploma or equivalent required.
Three years' hospital billing, denials management, utilization review support, or related revenue cycle experience.
Experience working outpatient clinical denials, or medical necessity line-item denials strongly preferred.
Working knowledge of outpatient clinical denial categories, including payer medical policy, experimental/investigational, and clinical criteria denials.
Familiarity with payer authorization processes and outpatient 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 outpatient denial drivers.
Strong written communication skills for documentation and internal coordination.
Proficiency with hospital billing systems, EMR navigation, and payer portals.
Must have ability to meet deadlines and attention to detail.
Must demonstrate good judgment.
Must be metric-driven and results oriented.

Nice To Haves

Associate or bachelor’s degree in healthcare or business-related field preferred.

Responsibilities

Reviews and triages outpatient clinical denials, including medical policy, experimental/investigational, and clinical criteria denials.
Routes cases to appropriate clinical resources (Clinical Appeals RN, ordering providers, authorization teams) based on denial type and appeal viability.
Maintains accurate outpatient clinical denial inventories, including deadlines, appeal levels, documentation status, and outcomes.
Coordinates medical record requests, appeal packet preparation logistics, and submission tracking.
Ensures compliance with payer requirements, timelines, and documentation standards for outpatient clinical denials.
Performs payer follow-up activities, including portal research and telephone outreach as needed.
Documents clear, concise, and accurate notes in the hospital billing system related to denial actions and status.
Identifies recurring outpatient clinical denial trends by payer, policy, procedure, or department and escalates findings to leadership.
Supports denial prevention initiatives by partnering with ordering providers, authorization teams, Revenue Integrity, and operational leaders.
Maintains current knowledge of payer outpatient medical policies and appeal processes.
Performs other duties as assigned and adapts to changing departmental demands.