Clinical Denials Specialist (On-Site)

***This role will work On-Site in Fairfield, CA***

At Northbay Health, the Clinical Denials Specialist performs advanced clinical and revenue cycle functions related to payer denials, including medical necessity, prior authorization, referrals, notifications, non-coverage determinations, and other denial categories as assigned. Reviews and analyzes denied claims, prepares and submits comprehensive appeals, collaborates with physicians, Health Information Management (HIM), Case Management, Coding, Patient Financial Services, and other interdisciplinary teams to resolve denials, identify root causes and denial trends, and support denial prevention and revenue optimization initiatives.

Executes the denial appeal process by receiving, reviewing, documenting, tracking, preparing, submitting, and resolving appeals with third-party payers in a timely manner for services provided to patients. Performs detailed clinical and coding reviews to support appeal development, ensures compliance with payer requirements and regulatory guidelines, and escalates complex cases as appropriate to maximize reimbursement and improve first-pass claim success.

Primary Job Duties

• Reviews and analyzes payer denials, including medical necessity, level of care, prior authorization, referrals, notifications, DRG validation, coding, documentation, non-coverage determinations, and other clinically related denials to determine the appropriate resolution strategy.
• Performs comprehensive reviews of the medical record, clinical documentation, coding, payer contracts, medical policies, CMS regulations, LCD/NCDs, InterQual®, MCG, and commercial payer guidelines to determine medical necessity, coding accuracy, appeal opportunities, and regulatory compliance

• Develops, prepares, and submits well-supported first-level and subsequent-level appeals utilizing clinical documentation, coding guidelines, payer policies, regulatory requirements, and evidence-based literature. Determines the appropriate appeal strategy and coordinates escalation to second-level appeals, arbitration, external review, peer-to-peer discussions, and Physician Advisor review as appropriate.

• Collaborates with physicians, Physician Advisors, Coding, Clinical Documentation Integrity (CDI), Health Information Management (HIM), Case Management, Utilization Management, Revenue Integrity, Patient Financial Services, and other interdisciplinary departments to obtain supporting documentation, strengthen appeals, resolve denials, and improve reimbursement outcomes.

• Reviews denied claims for coding accuracy, documentation completeness, and charge integrity, identifying opportunities for coding clarification, clinical documentation improvement, charge capture enhancement, and revenue recovery prior to appeal submission.

• Prioritizes high-dollar, high-risk, and complex denials to maximize reimbursement and performs financial impact analyses to identify recovery opportunities and revenue leakage.

• Performs root cause analyses of denial trends to identify opportunities related to documentation, coding, registration, authorization, utilization management, clinical workflows, and operational processes. Collaborates with operational leaders to implement corrective actions and denial prevention strategies.

• Develops and delivers education to physicians, coding professionals, CDI specialists, case management, utilization management, revenue cycle departments, and other clinical staff regarding payer requirements, documentation standards, coding guidelines, medical necessity criteria, denial trends, and specialty-specific opportunities to reduce future denials.

• Serves as a subject matter expert on payer medical necessity requirements, CMS regulations, Medicare Advantage policies, commercial payer policies, coding regulations, reimbursement methodologies, and industry best practices. Monitors regulatory and payer policy changes and communicates operational impacts to leadership and affected departments.

• Participates in payer discussions, peer-to-peer reviews, defense audit, external audits, Recovery Audit Contractor (RAC), Medicare Advantage, commercial payer audits, DRG validation audits, and other payer review activities to support reimbursement and regulatory compliance.

• Partners with Revenue Integrity and operational departments to identify reimbursement opportunities, improve charge capture, optimize clinical and revenue cycle workflows, and implement initiatives that reduce avoidable denials and improve financial performance.

• Tracks denial inventory, appeal outcomes, overturn rates, financial recoveries, payer performance, denial trends, and key performance indicators using reporting and analytics tools. Develops dashboards and presents findings and recommendations to Revenue Cycle leadership to support operational decision-making and continuous process improvement.

• Maintains complete and accurate documentation of appeal activity, payer communications, decisions, supporting evidence, and related records in accordance with organizational policies and regulatory requirements.

• Performs other duties as assigned.

Education:

• Associate degree required or equivalent combination of education and experience equal to 4 years.

• Bachelor's preferred.

Licensure/Certification:

• Clinical license or certification required.

• CCS, RHIT, or CPC certification required.

Experience:

• Minimum of three years of experience in acute care hospital.

Skills:

• Must be capable of mature and independent judgment.

• Ability to investigate, analyze and resolve issues at a high level.

• Must have excellent communication, organizational and problem-solving skills.

• Possess strong analytic, research and report writing skills. Knowledgeable of federal, state and private agency review requirements and regulations.

• Must be competent in Microsoft Office programs including Outlook and Word and Excel required.

• Utilizes critical thinking and applies sound clinical judgment and assessment skills for decision making.

Interpersonal Skills:

• Demonstrates the True North values. The True North values are a set of value-based behaviors that are to be consistently demonstrated and role modeled by all employees that work at NorthBay Health. The True North values principles consist of Nurture/Care, Own It, Respect Relationships, Build Trust and Hardwire Excellence. Demonstrates the willingness to research, learn, and obtain knowledge for the performance of the position. Demonstrates a courteous, professional demeanor and team spirit and the ability to work in a collaborative, effective manner.

Standards of Performance:

• Demonstrate performance by adhering to established policies and procedures and exhibiting the defined characteristics associated with attendance and punctuality.

Physical Effort:

• Attendance is an essential function of the job. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.  While performing this job, the employee may participate in the following activities: walking, periods of sitting, keyboarding, and standing.

Hours of Work:

• Hours based on business need. Mostly Monday – Friday, 8-5.