Clinical Denial Specialist

Franciscan Health

. Function as a hospital liaison to appeal denied Medicare, Medicaid, Managed, and Commercial insurance claims .

Posted 11/3/2026full-timeRemote • United StatesMid-LevelSenior💰 $67,142 - $92,331 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in appealing denied insurance claims, conducting medical record reviews, and ensuring compliance with Medicare and Medicaid guidelines. Proficient in analyzing data and collaborating with clinical teams to improve documentation processes.

Highest-signal resume keywords

Bachelor's Degree In NursingActive Indiana RN LicenseDenial Related ExperienceKnowledge Of Medicare And Medicaid RequirementsExperience With EPIC

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Record ReviewData AnalysisReport DevelopmentAudit Medical DocumentationEstablish Medical Necessity Letters

Soft Skills

CollaborationAttention To DetailCommunication

Tools & Technologies

EPIC

Certifications & Qualifications

Registered Nurse (RN)

Industry Keywords

MedicareMedicaidManaged InsuranceCommercial InsuranceInpatient CriteriaClinical Documentation Integrity

About the role

Key responsibilities & impact

Function as a hospital liaison to appeal denied Medicare, Medicaid, Managed, and Commercial insurance claims
Conduct detailed retrospective reviews of patient medical records in EPIC
Analyze and compile data for additional documentation requests and claim denials
Develop reports
Review governmental contractor responses
Identify root causes of potential denials and collaborate with departments and Clinical Documentation Integrity on process improvement
Write and timely file appeals
Audit medical documentation for adherence to insurance and CMS guidelines for inpatient and observation services
Establish medical necessity letters using inpatient criteria

Requirements

What you’ll need

Bachelor's degree in Nursing or Associate degree in Nursing with 5 years of nursing experience required
Active Indiana RN license required
3 years of denial related experience required
5 years Nursing or Case Management preferred
Knowledge of inpatient criteria
Knowledge of Medicare, Medicaid, Managed, and Commercial insurance requirements
Experience with EPIC and medical record review
Ability to work Monday–Friday, 8:00 a.m.–4:30 p.m. EST

Benefits

Comp & perks

Comprehensive benefit offerings for eligible employees