Team Leader - Clinical Denials

• Bachelor’s degree in nursing, Healthcare Administration, Health Information Management, or related field.
• Valid Philippine RN license/PRC registration for RN-required positions.
• 3 to 5 years of experience in U.S. healthcare RCM, clinical denials, CDI, utilization management, claims, or appeals.
• Demonstrated experience leading or mentoring healthcare teams, preferably 20+ employees.
• Strong knowledge of medical necessity, DRG, level of care, clinical documentation, coding, reimbursement, and U.S. payer policies.
• Strong communication, analytical, problem-solving, and people-management skills.
• Willingness to work U.S.-aligned shifts as required.

• CDAS or equivalent denial management credential.
• CCDS/CDIP or equivalent CDI certification.
• CCS/CPC or equivalent coding certification.
• Experience with Epic and U.S. payer portals.
• Experience managing denial inventory and performance dashboards.

Duties and Responsibilities

• Leads daily activities of a team of 20+ Clinical Denials Specialists.
• Assigns and prioritizes denial inventory based on complexity, aging, financial impact, and payer requirements.
• Monitors productivity, quality, turnaround time, and appeal outcomes.
• Provides coaching, mentoring, and performance feedback.
• Supports onboarding and training of team members.
• Escalates operational, clinical, payer, and client issues to management.

• Reviews complex and high-dollar clinical denials.
• Provides guidance on medical necessity, DRG, level of care, clinical validation, documentation, and coding-related denials.
• Reviews appeal letters for accuracy, completeness, and supporting evidence.
• Supports interpretation of U.S. payer policies and reimbursement requirements.
• Collaborates with CDI, HIM, Coding, Utilization Management, and other RCM stakeholders.

• Partners with QA to address quality findings and performance gaps.
• Identifies recurring denial trends and opportunities for prevention.
• Supports root-cause analysis and process improvement initiatives.
• Ensures work complies with client requirements, payer policies, privacy, and organizational standards.

• Reviews team performance reports and KPIs.
• Communicates trends, risks, and action plans to management.
• Supports client and internal meetings as required.
• Maintains effective communication with U.S.-based stakeholders.