QA - Clinical Denials

• Bachelor's degree in Nursing, Healthcare Administration, Health Information Management, or related healthcare field.
• Active RN license or applicable clinical credential.
• Minimum 2 to 3 years of healthcare experience in clinical denials, CDI, utilization management, coding, RCM, claims, appeals, or related areas.
• Experience reviewing medical records and clinical documentation.
• Strong knowledge of medical terminology, clinical documentation, coding principles, reimbursement, and payer requirements.
• Strong analytical and problem-solving skills.
• Excellent written and verbal communication skills.
• Strong attention to detail and ability to identify discrepancies.
• Ability to work independently while meeting productivity and quality expectations.

• Experience in clinical denials or denial QA.
• CDAS or equivalent denial management credential.
• CCDS, CDIP, or equivalent CDI credential.
• Coding certification such as CCS, CPC, or equivalent.
• Experience with inpatient DRG, medical necessity, clinical validation, and level-of-care reviews.
• Experience with Epic or other EHR systems.
• Experience with payer denial management portals.
• Experience using QA scorecards, audit tools, and reporting dashboards.

Duties and Responsibilities

• Conducts routine and targeted quality audits of clinical denial reviews and appeals.
• Reviews denied claims, medical records, billing information, payer correspondence, and appeal documentation.
• Evaluates accuracy of denial identification, clinical analysis, coding validation, and appeal rationale.
• Validates that appeal arguments are supported by medical records, clinical documentation, coding guidelines, payer policies, and applicable reimbursement requirements.
• Reviews clinical denial cases for medical necessity, clinical validation, DRG, level-of-care, documentation, coding, and other denial categories.
• Identifies critical, major, and minor quality errors based on established QA standards.
• Ensures appeals are complete, accurate, timely, and appropriately supported.
• Validates appropriate use of clinical terminology, coding concepts, payer requirements, and regulatory guidance.
• Performs random, targeted, and focused audits based on business requirements and identified risk areas.

• Applies standardized QA scorecards and audit methodologies consistently.
• Documents audit findings accurately and objectively.
• Maintains QA records, audit results, error classifications, and supporting evidence.
• Identifies recurring quality issues and trends.
• Prepares individual and team-level quality reports.
• Tracks quality performance against established targets.
• Escalates significant quality, compliance, or clinical concerns to the appropriate leadership.

• Provides timely and constructive feedback to Clinical Denials Specialists.
• Explains identified errors and appropriate corrective actions.
• Partners with Team Leads to support coaching and remediation.
• Identifies training opportunities based on audit findings.
• Participates in calibration sessions to promote consistency among reviewers and QA staff.
• Supports development and maintenance of QA reference materials and job aids.

• Ensures reviewed work follows client policies, payer requirements, regulatory standards, and organizational procedures.
• Monitors changes in payer policies, coding guidelines, reimbursement requirements, and regulatory expectations that may affect QA standards.
• Identifies process gaps that contribute to quality issues or denial leakage.
• Recommends process improvements based on audit findings.
• Participates in denial prevention and quality improvement initiatives.
• Supports root-cause analysis of recurring errors.

• Collaborates with Clinical Denials Specialists, Team Leads, Managers, CDI, HIM, Coding, and other revenue cycle teams.
• Participates in QA and denial management meetings.
• Provides subject-matter input on complex or disputed audit findings.
• Supports client-specific quality requirements and audit requests.
• Performs other duties as assigned.