QA Team Lead - Clinical Denials

• Bachelor's degree in Nursing, Healthcare Administration, Health Information Management, or related healthcare field.
• Active RN license or applicable clinical credential.
• Minimum 4 to 5 years of healthcare experience in clinical denials, CDI, utilization management, coding, RCM, appeals, or related areas.
• Minimum 1 to 2 years of QA, auditing, team leadership, or supervisory experience.
• Strong knowledge of clinical documentation, medical necessity, coding, reimbursement, inpatient DRG, level of care, and payer requirements.
• Demonstrated ability to analyze quality data and identify trends.
• Strong leadership, communication, coaching, and problem-solving skills.
• Excellent attention to detail.

• CDAS or equivalent denial management credential.
• CCDS, CDIP, or equivalent CDI certification.
• CCS, CPC, or equivalent coding certification.
• Experience leading clinical denial QA programs.
• Experience developing QA scorecards and audit methodologies.
• Experience with Epic, EHR systems, and payer portals.
• Experience with reporting tools, dashboards, and data analytics.
• Experience supporting multiple clients or large-scale RCM programs.

Duties and Responsibilities

• Leads daily activities of the Clinical Denials QA team.
• Assigns and prioritizes QA audits based on workload, risk, denial type, financial impact, and business requirements.
• Monitors QA productivity, audit completion, accuracy, turnaround time, and quality performance.
• Provides coaching, mentoring, and performance feedback to QA staff.
• Supports onboarding, training, and competency development of QA team members.
• Ensures appropriate coverage and distribution of QA workload.
• Escalates significant performance, quality, compliance, and operational concerns to management.

• Oversees routine, targeted, and focused audits of clinical denial reviews and appeals.
• Conducts complex and high-dollar case audits.
• Reviews escalated or disputed QA findings.
• Ensures audit findings are supported by objective evidence.
• Validates consistent application of QA scorecards and error definitions.
• Monitors adherence to client-specific quality requirements.
• Ensures critical quality and compliance issues are appropriately escalated.
• Reviews trends in clinical, coding, documentation, reimbursement, and appeal quality.

• Maintains and updates QA scorecards, audit tools, and quality standards.
• Leads regular calibration sessions for QA staff and operational teams.
• Establishes consistent interpretation of clinical, coding, payer, and quality requirements.
• Identifies areas of disagreement between QA and operations and facilitates resolution.
• Partners with management to establish quality targets and performance expectations.
• Supports development of standardized QA methodologies across clients and programs.

• Analyzes individual, team, client, payer, and denial-category quality trends.
• Prepares QA dashboards and management reports.
• Identifies recurring error patterns and systemic quality risks.
• Tracks critical error trends and corrective action effectiveness.
• Provides insights into the relationship between quality performance and denial recovery.
• Presents quality findings and recommendations to operational leadership.
• Supports client reporting and business reviews as required.

• Partners with Team Leads and Managers to address quality performance issues.
• Provides actionable feedback based on audit findings.
• Identifies training and competency gaps.
• Develops recommendations for targeted training and remediation.
• Monitors effectiveness of corrective actions.
• Supports performance improvement plans where appropriate.
• Ensures feedback is timely, objective, consistent, and documented.

• Identifies systemic issues contributing to inaccurate or unsuccessful appeals.
• Partners with Clinical Denials, CDI, HIM, Coding, Utilization Management, and RCM leadership to address root causes.
• Recommends workflow, training, documentation, and process improvements.
• Participates in denial prevention initiatives.
• Identifies opportunities to improve appeal quality and denial recovery.
• Supports implementation of standardized best practices across teams and clients.

• Maintains knowledge of payer policies, reimbursement guidelines, coding principles, clinical documentation requirements, and applicable regulations.
• Ensures QA standards remain aligned with current requirements.
• Identifies potential compliance risks and escalates appropriately.
• Supports internal and client audits as required.
• Maintains confidentiality of patient and client information.

• Partners with Clinical Denials Team Leads and Managers to improve operational quality.
• Participates in client meetings and quality reviews when required.
• Communicates quality trends, risks, and recommendations clearly and professionally.
• Supports client-specific audit requirements.
• Serves as an escalation point for complex or disputed QA findings.