Inpatient Clinical Denial Specialist

Capital Health is a leader in providing quality patient care with investments in physicians, nurses, staff, and advanced technology. The role involves administrative management, tracking, and coordination of inpatient clinical denials, including patient status determinations, medical necessity denials, and readmission-related denials. The specialist ensures denial cases are triaged, routed, documented, tracked, and prepared for appeal in line with payer requirements, collaborating with clinical and operational resources.

Responsibilities include reviewing and triaging inpatient clinical denials, routing cases to appropriate clinical resources, maintaining denial inventories, coordinating medical record requests and appeals submissions, ensuring compliance with payer timelines and documentation, performing payer follow-ups, documenting denial actions in hospital billing systems, identifying denial trends, supporting denial prevention by partnering with clinical teams, and staying current on payer denial practices.

The position requires a high school diploma or equivalent, with preference for an associate or bachelor's in healthcare or business. Experience includes three years in hospital billing, denials management, utilization review support, or related revenue cycle experience; experience with inpatient clinical denials strongly preferred. Skills needed include knowledge of inpatient clinical denial categories, utilization review processes, strong organizational and communication skills, proficiency in hospital billing systems, EMR navigation, payer portals, and Microsoft Office applications.

Physical demands include lifting up to 15 lbs, and the role requires attention to detail, ability to meet deadlines, good judgment, and being metric-driven and results-oriented.