Team Lead - Denials Prevention

University of Maryland Medical System; Linthicum (MD); On-site; USD 110,000 - 140,000; Full time

Job summary

University of Maryland Medical System Corporation is seeking an experienced nurse to support the Denials Prevention Team. The role focuses on clinical denial management, utilization review, and regulatory compliance to optimize reimbursement outcomes across the health system.

Lead clinical resource duties include mentorship, education, and quality oversight while collaborating with physicians, CDI, coding, and revenue cycle leaders to identify denial trends and drive process improvements.

Qualifications

• Bachelor of Science in Nursing and active Maryland RN license.
• Certification in Case Management, Utilization Management, Revenue Cycle, CDI or related specialty.
• Five years of professional nursing experience in acute care.
• Three years in clinical denials management, utilization review, or revenue cycle operations.

Responsibilities

• Assist the Director in supporting daily operations and oversight of the Denials Prevention Team.
• Serve as lead clinical resource and SME for reimbursement denials and utilization management.
• Provide guidance, mentorship, education, and quality oversight to staff.
• Collaborate with physicians, revenue cycle leaders, case management, coding, CDI, and patient financial services to identify denial trends and optimize reimbursement.
• Develop reports, educational materials, and presentations on denial trends and payer activity.
• Participate in recruitment, onboarding, and staff development; provide feedback on performance.
• Perform other related duties as assigned.

Skills

Clinical denial management

Regulatory compliance

Denials analytics

Payer audits

Education

BSN

RN license Maryland

Certification in Case Management/Utilization Management/CDI

Job description

Job Requirements

Under limited supervision, assists the Director, Clinical Appeals & Denials Analytics in supporting the daily operations and oversight of the Denials Prevention Team. Serves as the lead clinical resource and subject matter expert for reimbursement denials, utilization management principles, regulatory requirements, and clinical documentation standards. Maintains an active workload while providing guidance, mentorship, education, quality oversight, and operational support to team members. Collaborates with physicians, physician advisors, revenue cycle leadership, utilization management, case management, coding, CDI, and patient financial services to identify denial trends, implement denial prevention strategies, and optimize reimbursement outcomes across the health system.

Job Requirements

Under limited supervision, assists the Director, Clinical Appeals & Denials Analytics in supporting the daily operations and oversight of the Denials Prevention Team. Serves as the lead clinical resource and subject matter expert for reimbursement denials, utilization management principles, regulatory requirements, and clinical documentation standards. Maintains an active workload while providing guidance, mentorship, education, quality oversight, and operational support to team members. Collaborates with physicians, physician advisors, revenue cycle leadership, utilization management, case management, coding, CDI, and patient financial services to identify denial trends, implement denial prevention strategies, and optimize reimbursement outcomes across the health system.

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job responsibilities performed.

• Demonstrates comprehensive expertise in clinical denial management, payer audits, root cause analysis, reimbursement processes, and regulatory compliance related to utilization management.


• Serves as the primary resource and escalation point for Denials Prevention RNs.


• Performs prospective and retrospective clinical audits/root cause analyses to identify opportunities for documentation improvement, denial prevention, front-end workflow optimization and back-end pre-bill review.


• Develops mitigation strategies and collaborates with physicians, physician advisors, physician leadership, CDI specialists, coding professionals, case management, utilization management, and revenue cycle stakeholders to implement strategies that optimize reimbursement outcomes.


• Assists in monitoring denial trend, reimbursement risks, and payer performance patterns across the health system.


• Develop reports, educational materials, and presentations related to denial trends, payer activity, and member organization performance metrics.


• Participates in recruitment and candidate selection. Provides onboarding, orientation, mentoring, and ongoing education to new and existing staff members.


• Assists leadership with staff competencies and professional development.


• Provides feedback regarding team member performance.


• Perform all other related duties as assigned.

Required

Work Experience

• Bachelor of Science in Nursing (BSN).


• Currently active Registered Nurse license in the State of Maryland.


• Certification in Case Management, Utilization Management, Revenue Cycle, CDI, or related specialty.


• Five (5) years of professional nursing experience in an acute care setting.


• Three (3) years of experience in clinical denials management, utilization review, case management, or revenue cycle operations.


• Demonstrated expertise in denial appeals, utilization management principles, and reimbursement regulations.

Preferred

• Lead, preceptor, educator, or supervisory experience.


• Experience with denial analytics, auditing, and performance improvement initiatives.


• Experience in CDI or coding