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Day - 08 Hour (United States of America)
This is a Stanford Health Care job.
A Brief Overview
The Senior Clinical Denials Appeal Specialist serves as a clinical subject matter expert focused on resolving and appealing clinically related, documentation-related, and clinical operations-related denials. This role performs detailed account and medical record reviews to assess and determine appropriate resolution activity, takes necessary actions to resolve clinical denials and prepares compliant, evidence-based appeal submissions when needed. The Senior Clinical Denials Appeal Specialist operates under established guidelines and supervision, ensuring accurate, timely, and consistent appeal decisions aligned with clinical criteria, regulatory requirements, and organizational standards. This role requires a strong understanding and application of clinical documentation standards, coding, and payor policy, as well as strong analytical and communication skills. The Senior Clinical Denials Appeal Specialist assists the organization by identifying trends in documentation or operational risk and ensures timely communication with appropriate denial prevention and management stakeholders.
Locations
Stanford Health Care
What you will do
Evaluates clinically related denials and takes necessary actions to resolve including preparing and submitting clinical appeal arguments and appeals to government, commercial, and managed care payers in accordance with federal, state, and local regulatory requirements.
Conduct thorough analyses of assigned denials, evaluating the clinical validity of diagnoses, appropriateness of medical services and procedures.
Ensures all appeal submissions are accurate, compliant, and submitted within required timelines.
Identifies missing or insufficient documentation and collaborates with internal departments to obtain needed information.
Maintains detailed and accurate documentation of appeal activity in designated systems.
Meets productivity, quality, and turnaround time expectations.
Follows standardized workflows, templates, and escalation protocols.
Operates within established guidelines with supervisory support as needed.
Education Qualifications
Experience Qualifications
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. UM or CM leadership experience preferred.
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.
Experience with Epic HB and PB highly desirable.
Required Knowledge, Skills and Abilities
Strong understanding of ICD-10-CM/PCS, CPT/HCPCS coding, and medical necessity guidelines.
Strong understanding of clinical operations within a hospital or ambulatory care setting
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 establish and maintain effective working relationships.
Working knowledge of hospital and physician revenue cycle systems, including Epic.
Licenses and Certifications
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. required Upon Hire
CCRC - Cert Clin Resch Coord preferred
These principles apply to ALL employees:
SHC Commitment to Providing an Exceptional Patient & Family Experience
Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford's patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.
You will do this by executing against our three experience pillars, from the patient and family's perspective:
Know Me: Anticipate my needs and status to deliver effective care
Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
Coordinate for Me: Own the complexity of my care through coordination
Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.
Base Pay Scale: Generally starting at $66.52 - $88.14 per hour
The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.