Clinical Appeals Specialist

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Sage Clinical RCM, LLC

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2024

🏥 Healthcare

☁️ SaaS

🤝 B2B

Healthcare • SaaS • B2B

Sage Clinical RCM is a healthcare revenue cycle management company that combines proprietary technology with clinical and financial expertise to provide end-to-end RCM solutions—from patient access through financial close. The firm offers advisory services, revenue cycle management operations, technology adoption (including clinical documentation improvement and autonomous coding), workforce augmentation (coding, documentation, RCM, physician advisory), and analytics-driven platforms (Sage IQ: Validity and VERO) that use automation and AI to unify coding, documentation, vendor performance, compliance, and financial reporting for healthcare organizations.

📋 Description

• Review medical records, denial letters, payer rationales, and supporting documentation to determine whether cases support appeals • Evaluate medical necessity and clinical validation using approved criteria, policies, clinical evidence, and coding guidance • Prepare concise, patient-specific appeal letters using approved templates • Connect documented clinical facts and evidence to the basis for each appeal • Use InterQual, MCG, the Pinson & Tang CDI Pocket Guide, encoding and grouping software, and AHA Coding Clinic guidance • Follow client priorities, escalation pathways, turnaround times, and workflows • Document appeal activity, status, actions, and outcomes in the tracking system • Collaborate with utilization review, CDI, coding, physicians, and revenue cycle stakeholders • Meet quality, productivity, and timeliness expectations • Identify denial trends, payer patterns, and documentation gaps and escalate findings • Maintain a secure remote work environment for protected health information • Comply with HIPAA, client security requirements, and Sage Clinical RCM confidentiality and information-security policies

🎯 Requirements

• Active RN, MD, or DO credential • Three to five years of experience in utilization review, clinical documentation integrity, coding, or related medical necessity or clinical validation work • Strong clinical reasoning and ability to synthesize complex medical-record information into defensible written appeals • Working knowledge of healthcare reimbursement, payer denials, documentation standards, and clinical findings' relationship to coded data • Strong professional writing, critical-thinking, organizational, and communication skills • Ability to work independently in a remote environment while following client-directed priorities and workflows • Reliable internet connectivity and ability to securely access client systems • Availability during the agreed-upon work schedule • Willingness to participate in virtual meetings, training, and workflow updates • Direct appeal-letter preparation experience preferred • Hospital or acute-care revenue cycle experience preferred • Experience with InterQual, MCG, encoder or grouping software, AHA Coding Clinic, or comparable resources preferred • Experience documenting appeal outcomes and identifying denial patterns preferred

🏖️ Benefits

• Remote work arrangement • Virtual meetings and training • Workflow updates and professional development through training