Houston Methodist · 1 week ago
Senior Denials Mgmt Specialist
Sugar Land, TX
Full-time
Onsite
Senior Level
7+ years expHouston Methodist is a leading healthcare institution, and they are seeking a Senior Denials Management Specialist. This role is responsible for performing utilization review activities and managing clinical denial processes in collaboration with clinical teams to ensure accurate reimbursement and mitigate financial risks.
Health CareMedical
Responsibilities
Perform utilization review activities and monitor the clinical denial management and appeals process in collaboration with clinical team partners
Use sound clinical judgement in the Utilization Management process and knowledge of regulatory requirements to make appropriate decisions
Review denials for level of care, medical necessity, and as appropriate, DRG recoupments/downgrades, and denials for no authorization
Communicate clinical information utilizing various resources and skills to reduce significant financial risk and exposure caused by unnecessary services provided
Facilitate accurate reimbursement and provide feedback for process and workflow opportunities to both operational and clinical stakeholders
Collaborate with physicians, case managers, and payors to ensure appropriate utilization of medical resources and services based on payor regulations and guidelines, and successfully appeal denials and develop meaningful appeal strategies
Qualification
Required
Bachelor's degree or higher from an accredited school of nursing
Seven years clinical nursing/patient care experience which includes three years in utilization review, case management or equivalent revenue cycle clinical role
RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)
Magnet-ANCC Recognized Certification (HM)
Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
Maintains knowledge of Federal, State, and local billing regulations and partners with managed care contracting as needed
Maintains knowledge of contracts, payor plans and benefits, billing/follow up procedures
Strong organizational and problem-solving skill as evidenced by capacity to prioritize multiple tasks and role components
Working knowledge of Microsoft products including PowerPoint, Word, Excel, and Outlook
Experience with clinical decision criteria such as InterQual, Milliman, etc
Demonstrates strong knowledge of commercial insurance and governmental programs, state and federal regulations and billing processes, managed care contracts and coordination of benefits related to coverage, clinical appeals, and denials to include knowledge of CPT and ICD codes and familiarity with Local Coverage Determination (LCD)/ National Coverage Determination (NCD)
Competence in writing clinical appeals for medical necessity compliance or level of care for government and nongovernmental payors
Ability to develop an appeal strategy and facilitate clinical appeals to ensure recovery
Preferred
Experience includes writing clinical appeals for medical necessity compliance or level of care for government and nongovernmental payers
Company
Houston Methodist
Houston Methodist is one of the nation’s leading health systems and academic medical centers.
10001+ employees
Funding
Current Stage
Late StageLeadership Team
Brooke Graham
CEO Project Director
David P. Bernard
Chief Executive Officer & Senior Vice President
Recent News
2025-12-07
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