Clinical Denials Specialist (PHRN/USRN) | Night Shift

Outsourcey Global, Inc.; Philippines; On-site; PHP 480,000 - 600,000; Full time

Benefits offered by this job

Travel opportunities

Job summary

Outsourcey Global, Inc. is seeking a Clinical Denials Specialist to review denied claims, gather clinical evidence, and build strong appeals. The role requires analyzing denial trends, collaborating with healthcare providers, and applying coding and reimbursement knowledge to improve denial prevention.

The ideal candidate holds an RN license with CDI or related credentials, a healthcare degree, and 2–3 years in revenue cycle or denial management. Travel to client sites may be needed.

Qualifications

• Bachelor’s degree in healthcare administration, nursing, health information management, or related field.
• Active RN license with clinical denials or CDI credentialing.
• 2–3 years of experience in healthcare revenue cycle, medical billing, claims processing, or denial management.
• Strong problem‑solving skills with ability to develop effective appeal strategies.
• Regulatory/mandatory certifications as required.
• Willingness to travel to client or organizational sites as needed.
• Preferred: CDAS or equivalent denial management credential.
• Preferred: Experience with EHR systems (Epic) and payer denial portals.

Responsibilities

• Reviews denied claims to identify denial reasons and discrepancies.
• Analyses medical records, billing documents, and payer policies to prepare appeal arguments.
• Applies coding knowledge and tools to validate diagnoses, procedures, modifiers, and other claim info.
• Demonstrates knowledge of inpatient DRG and level-of-care concepts and their relation to documentation and DRG assignment.
• Collaborates with healthcare providers to gather documentation and evidence for appeals.
• Develops effective, well-supported appeal strategies to overcome denials.
• Documents appeal activities, correspondence, and outcomes for tracking and reporting.
• Analyzes denial reasons and trends to identify opportunities for process improvement.
• Monitors denial trends and provides feedback to revenue cycle teams to prevent future denials.
• Participates in denial management meetings to improve denial prevention strategies.

Skills

Problem solving

Analytical thinking

Written communication

Education

Bachelor's degree in healthcare

RN license with CDI credentialing

Regulatory certifications

Tools

Epic EHR

Payer denial portals

Job description

About the role

The Clinical Denials Specialist plays a vital role in ensuring accurate reimbursement for healthcare services by reviewing denied claims, identifying denial reasons, and appealing claim denials. This role collaborates closely with healthcare providers to gather the documentation and clinical evidence needed to build strong appeals, analyzes denial trends across the organization, and provides feedback to revenue cycle teams to help prevent future denials. Success requires a blend of clinical knowledge, coding and reimbursement expertise, and sharp analytical and writing skills.

Key responsibilities

• Reviews denied claims to identify denial reasons and discrepancies
• Analyzes medical records, billing documents, and payer policies to prepare appeal arguments
• Applies coding knowledge and industry-standard tools to validate diagnoses, procedures, modifiers, and other claim-related information and identify potential coding-related denial issues
• Demonstrates knowledge of inpatient (IP) DRG and level-of-care concepts, including the relationship between clinical documentation, severity of illness, intensity of services, medical necessity, and DRG assignment
• Collaborates with healthcare providers to gather additional documentation and evidence for appeals
• Develops effective, well-supported appeal strategies to overcome denial challenges
• Documents appeal activities, correspondence, and outcomes for tracking and reporting purposes
• Analyzes denial reasons and trends to identify opportunities for process improvement
• Monitors denial trends and provides feedback to revenue cycle teams to prevent future denials
• Participates in denial management meetings and contributes insights to improve denial prevention strategies

About you

• Bachelor's degree in Healthcare Administration, Nursing, Health Information Management, or a related field
• Active RN license with clinical denials or Clinical Documentation Improvement (CDI) credentialing
• Minimum of 2-3 years of experience in healthcare revenue cycle management, medical billing, claims processing, or denial management
• Strong problem-solving skills with the ability to develop effective appeal strategies
• Completion of regulatory/mandatory certifications as required
• Willingness and ability to travel to client or organizational sites as needed
• Preferred: Certified Denials and Appeals Specialist (CDAS) or equivalent denial management credential
• Preferred: Experience with EHR systems, such as Epic, and payer denial management portals