Denials Management Specialist

JOB SUMMARY

The Denials Management Review Specialist is responsible for performing comprehensive clinical and regulatory review of records submitted in response to payer, government, and external audit requests. This role evaluates documentation for medical necessity, eligibility, compliance with Medicare, Medicaid, payer, and program-specific requirements, and overall defensibility of the claim. The position partners closely with agency leadership, clinical operations, revenue cycle, finance, legal, and compliance teams to support timely audit response, identify documentation risk, communicate trends, and contribute to process improvements that reduce denial exposure and strengthen audit outcomes.

ESSENTIAL DUTIES & RESPONSIBILITIES

• Consistently demonstrates CAPLICO Core Values and complies with the organization’s Code of Conduct, confidentiality standards, and applicable policies and procedures.
• Manages assigned audit reviews from intake through submission, including Additional Documentation Requests (ADRs), Targeted Probe and Educate (TPE), Unified Program Integrity Contractor (UPIC), Supplemental Medical Review Contractor (SMRC), Recovery Audit Contractor (RAC), Medicare Administrative Contractor (MAC), Medicaid, managed care, and other payer or regulatory reviews.
• Reviews medical records for completeness, accuracy, medical necessity, eligibility, certification/recertification support, plan of care compliance, visit documentation, orders, signatures, and other payer-specific documentation requirements.
• Applies Medicare Conditions of Payment, Medicare Benefit Policy Manual guidance, Medicaid requirements, payer policies, hospice and home health regulatory standards, and internal review expectations when evaluating claim defensibility.
• Identifies documentation gaps, audit vulnerabilities, technical deficiencies, and recurring denial drivers; clearly communicates findings to agency and clinical leaders in a professional, objective, and actionable manner.
• Prepares organized audit packets and review summaries that support timely, accurate, and defensible submissions to external reviewers, payers, and government contractors.
• Supports appeal development by analyzing denied claims, summarizing clinical and regulatory support, and assisting with documentation review for all applicable appeal levels.
• Partners with agencies, clinical operations, revenue cycle, finance, compliance, and legal partners to coordinate audit response activities, clarify documentation needs, and support appropriate follow-up.
• Provides recommendations for corrective action, process improvement, and targeted education based on audit findings and identified risk trends.
• Maintains proficiency in required systems and tools, including HCHB, EMR platforms, PDF-X-Change, Excel, Smartsheet, payer portals, and other audit tracking or reporting platforms.
• Demonstrates sound judgment, strong critical thinking, attention to detail, organization, flexibility, and the ability to manage multiple deadlines in a remote, fast-paced environment.

The above statements are intended to describe the general nature and level of work performed by individuals assigned to this position. They are not intended to be an exhaustive list of all responsibilities, duties, or skills required. Incumbents may be asked to perform other job-related duties as assigned and in alignment with organizational needs.

JOB REQUIREMENTS (Education, Experience, Knowledge, Skills & Abilities)

• Registered Nurse or other applicable clinical licensure strongly preferred; equivalent clinical, audit, compliance, revenue cycle, or denials management experience may be considered based on business need.
• Minimum of five years of experience in home health, hospice, post-acute care, clinical documentation review, audit response, appeals, compliance, or denials management preferred.
• Strong working knowledge of Medicare, Medicaid, managed care, and payer documentation requirements, including home health and hospice eligibility, medical necessity, certification, recertification, plan of care, orders, signatures, and visit documentation standards.
• Ability to interpret payer audit requests, identify required documentation, evaluate record completeness, and organize submission packets accurately and timely.
• Demonstrated ability to synthesize complex clinical, operational, and regulatory information into clear findings, recommendations, and education opportunities.
• Excellent written and verbal communication skills, including the ability to provide professional, objective feedback to agency and clinical leaders.
• Highly detail-oriented, deadline-driven, and able to prioritize competing assignments with minimal supervision.
• Comfortable working independently in a remote environment while maintaining strong collaboration with cross-functional partners.
• Proficient with healthcare information systems, electronic medical records, Microsoft Office applications, Excel, PDF tools, Smartsheet, payer portals, and audit tracking or reporting platforms.