Clinical Appeals Specialist

What this role involves

The Clinical Appeals Specialist reviews clinical denials related to medical necessity and clinical validation, and writes evidence-based appeal letters to support reimbursement. The role involves analyzing medical records, payer denial rationales, and coding guidance, and collaborating with utilization review, CDI, coding, physician, appeals, and revenue cycle teams. Sage Clinical RCM provides operational oversight, while client staff direct daily priorities.

Skills this posting asks for

• medical necessity
• clinical validation
• appeal letters
• medical records analysis
• payer denial rationales
• clinical evidence
• coding guidance
• utilization review
• clinical documentation integrity
• coding
• revenue cycle

From the employer’s posting

Job DescriptionThe Clinical Appeals Specialist reviews clinical denials involving medical necessity and clini