ERISA Recovery · 1 day ago
Clinical Denials Specialist / Utilization Management
Plano, TX
Full-time
Onsite
Mid, Senior Level
3+ years expERISA Recovery is a fast-growing company based in Dallas, TX, specializing in the recovery of aged and complex claims using the Federal ERISA appeals process. The Clinical Denials Specialist will analyze denied claims, prepare appeals, and ensure medical necessity documentation aligns with payer requirements while collaborating with internal teams and insurance providers.
FinanceHealth CareMedical
Responsibilities
Review clinical documentation and denial letters to assess the reason for denial
Conduct thorough clinical reviews for inpatient and outpatient cases
Utilize InterQual, MCG (Milliman), and McKesson review criteria to determine medical necessity
Draft and submit clinical appeals and peer-to-peer reviews as needed
Collaborate with ER case managers, physicians, and utilization review teams to gather and validate required documentation
Evaluate and resolve issues related to pre-certifications, authorizations, and continued stay reviews
Maintain up-to-date knowledge of payer policies, CMS guidelines, and industry standards
Track denial trends and provide feedback for process improvement initiatives
Qualification
Required
Registered Nurse (RN) – active license required
Minimum of 3-5 years of clinical experience in Utilization Management (UM)
Minimum of 3-5 years of clinical experience in Clinical Review and Inpatient Case Management
Minimum of 3-5 years of clinical experience in Emergency Room (ER) Case Management
Strong experience with Medical necessity criteria tools: InterQual, MCG/Milliman, McKesson Review
Strong experience with Pre-certifications, authorizations, and continued stay reviews
Proven track record of successful appeal writing and overturning denials
Familiarity with payer-specific guidelines and reimbursement models
Excellent critical thinking, clinical judgment, and written communication skills
Preferred
Case Management Certification (e.g., CCM) a plus
Experience with denial analytics and reporting tools
Knowledge of Medicare Advantage and Medicaid Managed Care regulations
Benefits
401(k)
401(k) matching
Dental insurance
Health insurance
Paid time off
Vision insurance
Paid lunches
Company
ERISA Recovery
ERISA Recovery specializes in healthcare claims services such as automated data-mining of claims and medicare reimbursements.
51-200 employees
Funding
Current Stage
Growth StageLeadership Team
Andre Kus
CEO
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