Specialist - Clinical Review

JOB TITLE
Specialist - Clinical Review

POSITION SUMMARY
The Specialist – Clinical Review is responsible for reviewing, analyzing, and appealing denied claims for Ambulatory Surgery Center (ASC) services. This role focuses on denials related to medical necessity, authorization/pre-certification, level of care, medical documentation, and payer policy determinations. The Specialist – Clinical Review collaborates with physicians, coding, billing, and revenue cycle teams to develop compelling clinical appeal arguments that maximize reimbursement and reduce avoidable denials.

ESSENTIAL FUNCTIONS

Denial Review & Appeals

• Review denied ASC claims to determine root cause and appeal opportunities.
• Analyze payer denial rationale related to:
  • Medical necessity
  • Prior authorization/pre-certification
  • Experimental/investigational services
  • Medical documentation deficiencies
  • Level of care determinations
  • Bundling and reimbursement disputes
• Conduct comprehensive clinical reviews of patient records, operative reports, physician documentation, and supporting medical records.
• Prepare and submit quality clinical appeal letters with supporting documentation.
• Manage first-level, second-level, reconsideration, and external review appeals.
• Track appeal status and ensure timely follow-up within payer filing deadlines.
• Escalate complex denial cases to leadership when appropriate.

Clinical Documentation Review

• Evaluate medical records for completeness and compliance with payer requirements.
• Identify missing clinical documentation that may impact reimbursement.
• Collaborate with physicians and clinical staff to obtain additional supporting documentation.
• Ensure appeal packets include all required clinical evidence and supporting records.

Revenue Recovery & Denial Prevention

• Identify denial trends and recurring payer issues.
• Recommend corrective actions to reduce future denials.
• Partner with Authorization, Coding, Billing, and Clinical Operations teams to improve front-end processes.
• Participate in denial management meetings and revenue recovery initiatives.
• Support revenue integrity efforts through ongoing analysis of payer policies and reimbursement guidelines.

Regulatory & Compliance

• Maintain compliance with Medicare, Medicaid, commercial payer, and regulatory requirements.
• Stay current on payer medical necessity criteria and utilization management guidelines.
• Ensure appeals are submitted in accordance with payer contractual requirements and appeal timeframes.
• Always maintain confidentiality and HIPAA compliance.

Reporting & Performance Management

• Document actions and appeal outcomes within the practice management system.
• Track appeal success rates, overturn rates, and recovered revenue.
• Assist with preparation of denial management reports and key performance indicators (KPIs).
• Monitor aging of denied accounts and prioritize high-dollar opportunities.

Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day. 

NOTE: The essential functions are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties. Specific tasks or responsibilities will be documented as outlined by the incumbent's immediate manager.

MINIMUM QUALIFICATIONS
•    Associate’s Degree or Diploma in Nursing, or higher, required.  Must possess a current, valid RN license in state of practice, temporary RN license in state of practice, or compact RN licensure for current state of practice.  
•    Minimum 2 years of experience reviewing and appealing medical necessity denials.
•    Minimum 3 years of healthcare revenue cycle, utilization review, case management, clinical appeals, or denial management experience.
•    Experience working with Ambulatory Surgery Centers, hospital outpatient departments, or surgical specialties strongly preferred.
•    Knowledge of Medicare, Medicaid, and commercial payer requirements.

PREFERRED QUALIFICATIONS
•    Certified Revenue Cycle Representative (CRCR)
•    Certified Professional Coder (CPC)
•    Certified Case Manager (CCM)
•    Utilization Review Certification
•    Prior ASC denial management experience
•    Experience with orthopedics, spine, pain management, GI, ophthalmology, or multispecialty ASC procedures

PHYSICAL DEMANDS/ENVIRONMENT FACTORS
OE - Typical Office Environment:  
•    Requires extensive sitting with periodic standing and walking.  
•    May be required to lift up to 20 pounds.  
•    Requires significant use of computer, phone and general office equipment.  
•    Needs adequate visual acuity, ability to grasp and handle objects.  
•    Needs ability to communicate effectively through reading, writing, and speaking in person or on telephone.  
•    May require off-site travel.

SUPERVISORY RESPONSIBILITIES
None

DIRECTLY REPORTING
Manager of Revenue Cycle Management

TYPE OF SUPERVISORY RESPONSIBILITIES
None

SCOPE AND COMPLEXITY
The Clinical Review Specialist is responsible for reviewing and resolving denied Ambulatory Surgery Center (ASC) claims by assessing medical necessity, authorization requirements, clinical documentation, and payer policy compliance. This role partners with clinical staff, coding, billing, and revenue cycle teams to develop and submit effective appeals that maximize reimbursement and support revenue recovery. Success requires strong clinical and analytical expertise, knowledge of payer regulations and appeal processes, and the ability to identify denial trends, recommend process improvements, and ensure compliance with regulatory and contractual requirements while managing sensitive patient information.