Denials Management Specialist

Job Title & Specialty Area: Denials Management Specialist

Department: Utilization Management

Location: Children's Health- Trinity Towers

Shift: Full-time Monday through Friday 8:00a to 5:00p (there is flexibility to start 30 minutes earlier or later)

Job Type: Remote, onsite attendance required 2 times a month (2nd and 4th Thursdays of each month)

Why Children's Health?

At Children's Health, our mission is to Make Life Better for Children, and we recognize that their health plays a crucial role in achieving this goal.

Through our cutting-edge treatments and affiliation with UT Southwestern, we strive to deliver an extraordinary patient and family experience, ensuring that every moment, big or small, contributes to their overall well-being.

Our dedication to promoting children's health extends beyond our organization and encompasses the broader community. Together, we can make a significant difference in the lives of children and contribute to a brighter and healthier future for all.

Summary:
Under the direction of departmental leadership, the Denial Management Specialist plays a critical role in managing medical, authorization, and reimbursement-related denials. This role supports organizational initiatives aimed at ensuring timely access to medically necessary services, appropriate reimbursement, and regulatory compliance. The Denial Management Specialist independently navigates complex payer requirements, applies clinical judgment to appeal strategies, analyzes denial trends, and collaborates across teams to resolve denials efficiently.

Responsibilities:
* Denial Management and Appeals
* Independently manage denial mitigation activities, including peer-to-peer reviews, expedited appeals, standard appeals, and retrospective reviews. Prioritize denials based on clinical urgency, potential delay of care, financial impact, payer timelines, and regulatory requirements. Review denial notifications, clinical documentation, and payer correspondence to determine appropriate appeal strategies. Facilitate and coordinate peer-to-peer discussions by ensuring providers are prepared with relevant clinical information, payer criteria, and supporting documentation. Escalate complex, high-risk, or time-sensitive denials according to established protocols.
* Clinical Review and Documentation Support
* Apply clinical judgment to evaluate medical necessity, authorization criteria, treatment plans, and supporting medical record documentation. Identify documentation gaps and collaborate with clinical teams to strengthen records supporting payer compliance and appeal success. Differentiate clinical versus administrative denials to determine appeal eligibility and resolution pathways. Support retrospective review processes for previously denied services requiring additional clinical or authorization intervention.
* Payer Policy and Regulatory Expertise
* Maintain a working knowledge of payer policies, authorization requirements, appeal rights, timelines, and reimbursement rules. Interpret payer contracts, benefit structures, and clinical criteria to ensure all allowable appeal and resolution options are pursued. Monitor compliance with applicable regulatory, accreditation, and organizational standards. Maintain accurate documentation to support audits, reporting, and regulatory readiness.
* Trend Analysis and Reporting
* Monitor denial trends by payer, diagnosis, service type, and treatment modality. Analyze denial data to identify root causes, patterns, and opportunities for process improvement. Share findings with leadership and stakeholders to support denial prevention and workflow enhancements. Contribute to reporting, dashboards, and quality improvement initiatives related to denial management.
* Collaboration and Communication
* Partner with revenue, managed care, patient access, pharmacy, and clinical teams to support timely denial resolution and reimbursement. Serve as a liaison between internal teams and payers to facilitate communication and resolution of complex cases. Participate in interdisciplinary meetings, work groups, and committees related to denial management and prevention.
* Education and Subject Matter Expertise
* Serve as a subject matter expert for denial management workflows, prioritization standards, and escalation pathways. Educate and support team members on payer requirements, clinical criteria, appeal processes, and documentation best practices. Assist with onboarding and training of new staff related to denial and appeal workflows. Provide ongoing guidance and problem-solving support to peers.
* Quality Assurance and Process Improvement
* Participate in quality assurance audits, appeal reviews, and workflow evaluations. Identify process, system, or documentation issues contributing to denials and recommend corrective actions. Collaborate with leadership to refine tools, templates, and standard operating procedures. Support continuous improvement initiatives that enhance financial performance and timely access to care.
* Additional Responsibilities
* Perform other duties as assigned to support departmental and organizational objectives. Adapt responsibilities as payer requirements, workflows, and organizational needs evolve.

How You’ll Be Successful:

WORK EXPERIENCE
* At least 3 years Authorization Experience, UM, CM or denial Management Required
* At least 5 years Clinical nursing experience Preferred

EDUCATION
* Four-year Bachelor's degree or equivalent experience Required

LICENSES AND CERTIFICATIONS
* RN Required

A Place Where You Belong

We put our people first. We welcome, value, and respect the beliefs, identities and experiences of our patients and colleagues. We are committed to delivering culturally effective care, creating meaningful partnerships in the communities we serve, and equipping and developing our team members to make Children’s Health a place where everyone can contribute.

Holistic Benefits – How We’ll Care for You:

· Employee portion of medical plan premiums are covered after 3 years.

· 4%-10% employee savings plan match based on tenure

· Paid Parental Leave (up to 12 weeks)

· Caregiver Leave

· Adoption and surrogacy reimbursement

As an equal opportunity employer, Children's Health does not discriminate against employees or applicants because of race, color, religion, sex, gender identity and expression, sexual orientation, age, national origin, veteran or military status, disability, or genetic information or any other Federal or State legally-protected status or class. This applies to all aspects of the employer-employee relationship including but not limited to recruitment, hiring, promotion, transfer pay, training, discipline, workforce adjustments, termination, employee benefits, and any other employment-related activity.