Denials Management Specialist (Healthcare)

TL;DR

Denials Management Specialist (Healthcare): Reviewing clinical records and audit submissions for medical necessity, eligibility, compliance, and claim defensibility with an accent on Medicare, Medicaid, payer requirements, and documentation quality. Focus on analyzing denial drivers, preparing defensible audit packets, supporting appeals, and coordinating corrective action across clinical, revenue cycle, finance, legal, and compliance functions.

Location: Remote within the USA

Company

Healthcare services are provided through home health and hospice agencies and senior living communities operated by independent subsidiaries across the United States.

What you will do

• Manage audit reviews from intake through submission, including ADR, TPE, UPIC, SMRC, RAC, MAC, Medicaid, managed care, and other payer reviews.
• Review medical records for completeness, medical necessity, eligibility, certification, plans of care, orders, signatures, and visit documentation.
• Prepare organized audit packets and review summaries for payers, government contractors, and external reviewers.
• Analyze denied claims and support appeal development across applicable appeal levels.
• Identify documentation risks and denial trends, then communicate actionable findings to agency and clinical leaders.
• Coordinate audit response, corrective action, process improvement, and targeted education with cross-functional partners.

Requirements

• Registered Nurse or other applicable clinical licensure is strongly preferred; equivalent clinical, audit, compliance, revenue cycle, or denials management experience may be considered.
• At least five years of experience in home health, hospice, post-acute care, clinical documentation review, audit response, appeals, compliance, or denials management is preferred.
• Strong knowledge of Medicare, Medicaid, managed care, payer documentation requirements, home health, and hospice eligibility standards.
• Ability to interpret audit requests, evaluate record completeness, organize submission packets, and synthesize complex clinical and regulatory information.
• Excellent written and verbal communication, critical thinking, attention to detail, organization, and deadline management skills.
• Proficiency with healthcare information systems, EMR platforms, Microsoft Office, Excel, PDF tools, Smartsheet, payer portals, and audit tracking platforms.

Culture & Benefits

• Remote work in a fast-paced environment with independent responsibility and cross-functional collaboration.
• Regular collaboration with agency leadership, clinical operations, revenue cycle, finance, legal, and compliance teams.
• Work focused on improving documentation quality, reducing denial exposure, and strengthening audit outcomes.