The Clinical Denials Prevention & Appeals Specialist role is entirely remote. The Clinical Denials Prevention & Appeals Specialist plays a critical role in optimizing the revenue cycle and supporting accurate reimbursement for Michigan Medicine. This position is responsible for researching payer denials, including those related to DRG downgrades both APR and MSDRGs, clinical validation issues by leveraging comprehensive knowledge of clinical documentation, medical coding (with special emphasis on ICD-10), payer policies, and healthcare regulations. The Specialist will utilize technology to track and monitor denial trends and coordinate documentation improvement efforts.

As a key resource for Clinical Documentation Integrity (CDI) & Coding, the Clinical Denials Prevention & Appeals Specialist collaborates with CDI specialists, coders, quality analysts, providers, and other healthcare team members to ensure accurate, high-quality clinical documentation supporting Michigan Medicine initiatives. This position involves performing high-level, complex primary and secondary clinical validation denial case reviews to obtain and scrutinize denials to identify potential grounds for appeal.

Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally.  Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.

• Take ownership of reviewing and appealing clinical validation denials.
• Obtain and scrutinize denials to identify potential grounds for appeal.
• Compile evidence and craft compelling appeal letters to challenge incorrect denials.
• Develop coherent documentation when concurring with a denial decision.
• Manage the submission process and vigilantly track the status of each denial appeal.
• Maintain records of denials, appeals outcomes, and training impact, and present regular reports to management.
• Illuminate common denial trends and clarify documentation requirements.
• Educational Impact: Beyond handling denials, the Clinical Denials Prevention & Appeals Specialist will play a pivotal role in advancing the knowledge and skills. Through targeted educational sessions:
  • Create and implement training programs aimed at minimizing denials and improving documentation practices.
  • Provide ongoing education and feedback to coding, clinical documentation, and billing staff.
• Empower the CDI team by fostering focus and precision during daily reviews.
• Analyze denial trends and root causes to develop targeted training and policy adjustment recommendations for leadership.
• Feedback will be provided on successful appeals, bolstering team morale and engagement by highlighting the tangible impact of their meticulous work
• Collaborate with leadership and CDI Coordinator to conduct new-hire training and orientation.

• A Bachelor's degree (or the equivalent education and experience) in health information technology and registration with the American Health Information Management Association as a RHIT or RHIA and or certification as an RN, or a Bachelor's degree and certification in Nursing and or NP, PA or MD.
• 3-5 years of CDI experience working with coded data associated with clinical documentation
• Experience analyzing clinical validation denials and appeal letters
• Either CCDS or CDIP credential, or obtain within 1 yr of hire
• Demonstration of proficiency in productivity, communication & leadership attributes
• Adhering to the MM remote work agreement

The work requirements allow for the majority or all the work to be completed offsite. On occasion, the employee may be required and must be available to work onsite if necessitated by unit leadership or their designee and/or the job requirements.

Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings.  Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.

Job openings are posted for a minimum of seven calendar days.  The review and selection process may begin as early as the eighth day after posting. This opening may be removed from posting boards and filled anytime after the minimum posting period has ended.

The University of Michigan is an equal employment opportunity employer.