Sr. Director, Clinical Denials - REMOTE

EnableComp•Franklin, TN

5d•Remote

About The Position

The Sr. Director, Clinical Denials, will serve as the primary clinical authority supporting clients with denial prevention, appeal strategy, payer policy compliance, and industry education. This role represents the vendorâs clinical expertise and partners with provider clients to optimize revenue integrity, improve appeal outcomes, and reduce denial exposure. The Sr. Director, Clinical Denials, provides advanced consultative guidance, supports process design, mentors internal teams, and ensures delivery excellence in all clinical denial-related engagements.This role requires an experienced clinical professional with extensive inpatient experience, a proven record of collaboration with clinicians and payers, root cause research and identification of denial, and a deep understanding of payer behavior and regulatory requirements.

Requirements

Minimum of 5 years of experience in clinical denials management or revenue integrity, with strong emphasis on DRG assignment and appeal writing.
Excellent written communication and clinical reasoning skills for crafting persuasive appeals and client documentation.
Strong knowledge of MS-DRG and APR-DRG methodologies, including Severity of Illness (SOI) and Risk of Mortality (ROM) classifications.
Proficiency with CMS rules, payer contracts, and medical necessity guidelines (InterQual, MCG).
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.
Regular and predictable attendance.

Nice To Haves

Registered Nurse (RN) with at least 10 years of acute care clinical experience (ICU, Medical-Surgical, or similar).
Experience working with or supporting multiple hospital or health system clients in a vendor, consulting, or outsourced revenue cycle capacity.
Familiarity with Electronic Health Record (EHR) systems such as Epic, Cerner, or Meditech, and denials management platforms.
Coding certifications such as Certified Clinical Documentation Specialist (CCDS), Certified Coding Specialist (CCS), or Certified Professional Coder (CPC) preferred but not required if clinical and denial management expertise is extensive.

Responsibilities

Serve as the vendorâs lead clinical subject matter expert on clinical denials management and prevention.
Partner with provider clients to design and implement best practices for denial prevention and appeal workflows.
Conduct complex clinical case reviews for DRG validation, identifying and defending clinically appropriate DRG assignments.
Develop and refine clinical appeal strategies and templates to improve success rates.
Analyze denial trends across multiple clients and provide actionable insights to reduce recurring clinical denials.
Collaborate with coding, Clinical Documentation Integrity (CDI), and client operations teams to ensure consistency in methodologies and documentation practices.
Support proposal and implementation teams by contributing clinical expertise to solution design and client onboarding.
Maintain deep familiarity with Centers for Medicare & Medicaid Services (CMS) regulations, payer guidelines, and medical necessity criteria such as InterQual and MCG Health (formerly Milliman Care Guidelines).
Represent the organization as a clinical expert in client meetings, audits, and appeal escalations.
Represent EnableComp as an industry expert at national and regional conferences, networking opportunities, community outreach events, and client meetings.
Serve as a spokesperson for the company through webinars, speaking engagements, panel discussions, and authored articles.
Develop white papers, policy briefs, industry reports, and thought leadership content to elevate the organization's presence in the RCM and policy landscape.
Engage with payers and provider networks to advocate for streamlined administrative processes, and enhanced reimbursement methodologies.
Lead client education sessions and internal training programs on Medicare Severity Diagnosis Related Group (MS-DRG) and All Patient Refined Diagnosis Related Group (APR-DRG) validation, clinical documentation integrity, and payer policy application.
Partner with the sales and client success teams to educate prospective and existing clients on EnableCompâs services, value proposition, and regulatory insights.
Provide in-depth RCM expertise in responding to RFPs, proposals, and client inquiries.
Conduct training sessions and presentations on complex claims and industry trends for internal teams and clients.