OP Clinical Denial/Appeal Specialist

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Nov 14, 2020


Job Description


To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

The OP Clinical Denial Specialist supports the organization by reducing financial liability and recovering lost revenue for coding and medical necessity denials. This individual is responsible for, but not limited to: managing medical denials by conducting a comprehensive review of clinical documentation, writing compelling arguments based on the clinical documentation and the medical policies of the payor, submitting appeals in a timely manner, and identifying/resolving denial trends to mitigate potential loss. The OP Clinical Denial Specialist will also handle audit-related / compliance responsibilities and other administrative duties as required. This individual works closely with colleagues within the organization and with managed care payers to resolve issues and expedite reimbursement on overturned appeals.



  • 1. Researches payer denials related to medical necessity, coding, etc resulting in denials and delays in payment.
  • 2. Evaluates Outpatient Clinical denials against medical record documentation, the coding of the encounter , payer policies and contracts, and coverage determinations to determine the viability of an appeal
  • 3. Compiles the supporting documentation by working in partnership with internal departments and uses technology, drafts detailed, customized appeal letters to payers in accordance with Medicare, Medicaid, Commercial, and YNHHS policies and procedures.
  • 4. Ensures and tracks receipt of appeals and timely follow-up with all submissions until determination is made.
  • 5. Identifies payer denial trends, triage discrepancies, ongoing medical necessity, coding, or service issues, and collaborate or escalate appropriately for resolution.
  • 6. Collaborate internally to provide educational opportunities derived from common themes discovered through the appeal process in an effort to prevent future denials .
  • 7. Track key denial data as they relate to departmental metrics and performance. Develop and maintain key metrics report including the identification of trends, action plans, etc. Attend organizational committees to present data, as required.
  • 8. Communicate directly with payer and coordinate meetings with contracting and payers as needed to support appeals process.
  • 9. Perform other duties as assigned.



Two (2) years of college or equivalent with familiarity with medical terminology and anatomy. Knowledge of coding , billing and the revenue cycle. Working knowledge of human anatomy and physiology, Disease process , demonstrated knowledge of medical terminology and the medical record.


Three to five years of coding and/or billing experience required. Previous experience with governmental and managed care denial/appeal process including familiarity with RAC. Experience with medical and insurance terminology, CPT, ICD coding structures, and billing forms (UB, 1500). Epic HB billing knowledge preferred.


Certified Coding Specialist (CCS), Certified Coding Specialist Physician based (CCS-P) certification through the American Health Information Management Association (AHIMA) and/or Certified Professional Coder (CPC) or Certified Outpatient Coder (COC) through American Academy of Professional Coders (AAPC) is required, or must be obtained within six months of hire.


In-depth knowledge of documentation elements within the medical record. Expertise in governmental payment policies and regulations including medical necessity, NCCI, OCE, and MUE policies and procedures. Ability to analyze and resolve coding and medical necessity payer denials through in depth knowledge of payer policies and appeal procedures. Previous experience with clinical denials and appeals for all payers is preferred.


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Job Info

Job: 22621

Department: HIM Coding
Status: Full Time Benefits Eligible
Shift: DAYS
Hours: 40