Sr. Clinical Denials Prevention Analyst (Remote)

Stanford Health Care

9d•$67 - $88•Remote

About The Position

The Senior Clinical Denials Prevention Analyst serves as a clinical subject matter expert focused on reducing clinically related, documentation-related, and clinical operations-related denials through data and account analysis. The role partners across clinical, operational, revenue cycle, and payer-facing teams to identify patterns, assess root causes, and recommend improvements across the care-to-claim continuum, both before and after claim submission. The analyst proactively engages stakeholders to develop data-informed remediation strategies, support workflow optimization, and establish upstream practices that mitigate avoidable denials and accelerate resolution of those that cannot be prevented. Using a range of analytics and financial analysis, the position monitors performance, uncovers systemic issues, and translates insights into practical, sustainable solutions. Through continuous improvement initiatives and targeted education, this role strengthens revenue integrity and enhances overall denial and revenue performance.

Requirements

Bachelor’s Degree (BSN) is highly preferred. Diploma or Associate’s Degree in Nursing accepted when accompanied by strong demonstrated competencies and significant experience.
Minimum of five (5) years in nursing with a minimum of two (2) years’ experience as Utilization Management Nurse in an acute care setting required.
Experience and working knowledge of 2 Midnight, Milliman, and InterQual Guidelines required.
Minimum of two (2) years of experience in denial prevention, denial recovery, clinical appeals, or related denial-management responsibilities within a healthcare setting.
Strong understanding of ICD-10-CM/PCS, CPT/HCPCS coding, and medical necessity guidelines.
Strong understanding of 2 Midnight, Milliman, and InterQual Guidelines
Familiarity with payer policies, reimbursement methodologies, and CMS guidelines (including Medicare/Medicaid rules) and common commercial payer practices.
Knowledge of CDI concepts, documentation standards, and revenue cycle processes.
Ability to apply high-level problem-solving skills to perform root cause analysis on denied accounts and develop actionable remediation strategies.
Ability to manage, organize, prioritize, multi-task and adapt to changing priorities.
Ability to communicate effectively in written and verbal formats including summarizing data, presenting results.
Ability to establish and maintain effective working relationships.
Working knowledge of hospital and physician revenue cycle systems, including Epic.
CA Registered Nurse - Valid license as a Registered Nurse issued by the California Board of Registered Nursing (BRN).
Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.

Nice To Haves

UM or CM leadership experience preferred.
Experience with Epic HB and PB highly desirable
CCRC - Cert Clin Resch Coord preferred

Responsibilities

Analyze denial and write-off data across payers to identify patterns, root causes, and prevention opportunities across clinical, documentation, coding, and charging processes for both pre-bill and post-bill denials.
Conduct denial reviews to identify gaps in documentation, UM or revenue cycle workflows, coding, and billing rules and collaborate with UM, CDI, coding, and case managers to address gaps and implement corrective actions.
Lead cross-functional root-cause analyses with UM, CDI, HIM, Coding, Case Management, Billing, and payer teams to design and implement remediation strategies.
Help develop and implement denial prevention strategies, workflows, and playbooks and monitor their effectiveness through regular KPI reporting.
Monitor payer policy changes, national guidelines, and CMS/Medicare/Medicaid updates to ensure compliance and timely adjustment of practices.
Maintain denial dashboards, action plans, and performance reports for leadership review.
Prepare summary findings of analysis for department leadership; maintain clear documentation of analyses and outcomes; escalate systemic risks and barriers as appropriate.
Provide root cause analysis and support the mitigation of denial and denial write-off trends.
Perform standard to moderately complex financial and operational analyses to quantify impact, inform decisions, and track benefits realization.