Clinical Denials and Appeals Specialist

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Affordable Housing Trust for Columbus and Franklin County

WebsiteLinkedInAll Job Openings

1 - 10 employees

Founded 2001

🤝 Non-profit

🏠 Real Estate

🌍 Social Impact

Non-profit • Real Estate • Social Impact

Affordable Housing Trust for Columbus and Franklin County is a nonprofit organization dedicated to providing affordable housing solutions for residents in Columbus and Franklin County. The trust works to support the development and preservation of affordable homes, ensuring that low-income individuals and families have access to safe and stable housing options. By collaborating with local governments, developers, and community organizations, the trust strives to address housing challenges and improve living conditions in the region.

📋 Description

• Generate comprehensive first-level, second-level, and escalated appeal letters for denied claims. • Develop compelling clinical arguments using medical records, physician documentation, industry standards, and payer policies. • Create appeal packages with all required supporting documentation and submit within payer timelines. • Track appeal status, deadlines, and outcomes to ensure timely follow-up. • Review and revise appeal content to improve quality, consistency, and overturn success rates. • Review and assess denials related to: • Medical necessity • Level of care • Clinical validation • Authorization issues • Audit findings • Conduct detailed chart reviews to validate payer rationale and determine appeal viability. • Analyze denial trends and identify opportunities for overturn and prevention. • Apply CMS regulations, Medicare guidelines, LCDs, NCDs, payer policies, and industry guidance to support appeal arguments. • Maintain current knowledge of ICD-10-CM/PCS coding requirements, DRG methodologies, and reimbursement regulations. • Monitor payer updates and regulatory changes impacting denials and appeals. • Assist in developing appeal templates, reference materials, and best practices. • Provide recommendations to improve appeal effectiveness and reduce future denials. • Contribute to denial prevention initiatives through trend analysis and education. • Partner with physicians, CDI specialists, case management, utilization review, coding, and HIM teams to strengthen appeal outcomes.

🎯 Requirements

• Active Registered Nurse (RN) license required; BSN preferred. • Minimum 5 years of clinical nursing experience. • Minimum 3–5 years of denials management & appeals generation. • Demonstrated success generating and overturning clinical denials. • Strong knowledge of: • Medical necessity criteria • DRG reimbursement methodology • ICD-10-CM/PCS • CPT/HCPCS • Medicare and Medicaid regulations • Commercial payer policies • Experience using InterQual and/or MCG criteria. • Strong proficiency in Microsoft Word and healthcare documentation systems. • Exceptional written communication and persuasive writing skills.

🏖️ Benefits

• Medical, dental, vision and life insurance • short/long-term disability • 401(K) and referral bonuses • Training opportunities and reimbursement for professional certifications • UASI's unique approach to employee appreciation which include birthday recognition, holiday gift selections, performance awards, and years of service awards