Director, Clinical Denials

The Director, Clinical Denials provides specialized operational and strategic leadership over the full scope of the organization's clinical denial management function. Reporting to the Sr. Director, Denials Management, this role is accountable for driving clinical appeal performance across medical necessity, level-of-care, length-of-stay, DRG clinical validation, and experimental or non-covered service denials for all payer types and service lines.

This leader owns the clinical denial function end to end, from the quality of individual appeal letters to the design of appeal workflows, the development of clinical appeal writers, and the cross-functional partnerships that address root causes before denials occur. The Director, Clinical Denials brings deep clinical expertise, a command of payer medical policy and clinical criteria tools, and the leadership presence to engage physician advisors, payer medical directors, and executive stakeholders with equal confidence.

For the right clinical leader, this role offers the opportunity to build a high-performing clinical appeals team, drive measurable financial impact, and shape the clinical denial strategy for a complex, multi-payer organization. It is a role where clinical knowledge and revenue cycle expertise converge, and where the work directly protects the organization's ability to care for patients.

Duties and Responsibilities

Clinical Denial Program Leadership

• Knows, understands, incorporates, and demonstrates the Healthrise Core Values in all interactions with team members, clients, and stakeholders.

• Own the strategy, operations, and performance of the clinical denial management function, including medical necessity, level-of-care, length-of-stay, DRG clinical validation, and non-covered service denials.

• Establish and maintain clinical appeal workflows, escalation pathways, and quality standards that ensure timely, accurate, and persuasive appeal submissions across all payer types.

• Set and monitor performance targets for clinical denial overturn rates, appeal yield, first-level resolution rates, and financial recovery by payer, service line, and denial category.

• Serve as the senior clinical subject matter expert and primary escalation point for high-dollar, high-complexity, or high-profile clinical denials that require director-level review and judgment.

• Report clinical denial performance, trends, and program updates to the Sr. Director regularly, with clear root cause analysis and forward-looking corrective action plans.

Clinical Appeal Development and Quality

• Lead the development, review, and continuous improvement of clinical appeal letter content, ensuring all submissions clearly articulate medical necessity using clinical documentation, evidence-based literature, and applicable payer criteria including InterQual, MCG/Milliman, CMS NCD/LCD, and payer-specific medical policies.

• Establish and maintain a clinical appeal library including templates, reference guides, payer-specific playbooks, and evidence-based clinical arguments organized by denial category and payer type.

• Implement a structured quality review process for clinical appeal letters produced by the team, with regular audits, calibration sessions, and individual coaching to drive consistent quality and overturn performance.

• Monitor payer policy changes, CMS regulatory updates, and clinical criteria revisions that affect clinical denial rationale and appeal strategy; translate changes into updated workflows and team education in a timely manner.

• Manage the full clinical appeals lifecycle from initial denial through first-level appeal, second-level appeal, peer-to-peer review, and external independent review organization (IRO) submission, ensuring appeal rights are preserved at every stage.

Physician Advisor and Peer-to-Peer Program

• Oversee the physician advisor program, including engagement of internal and contracted physician advisors for clinical validation reviews, appeal support, and concurrent denial management.

• Manage the peer-to-peer review workflow, ensuring requests are initiated within payer-required timeframes, treating physicians are briefed with the clinical rationale and supporting documentation needed for each review, and outcomes are tracked.

• Build and maintain working relationships with payer medical directors and clinical review staff to facilitate resolution of complex clinical disputes and establish constructive channels for appeal discussions.

• Collaborate with Utilization Review leadership to identify and address concurrent denial trends that indicate documentation or authorization gaps driving retrospective clinical denials.

Clinical Collaboration and Denial Prevention

• Partner with Case Management, Utilization Review, CDI, and attending physicians to strengthen the clinical documentation supporting medical necessity determinations before and during the denial appeal process.

• Develop and deliver clinical documentation education for nursing, case management, and physician staff, focused on the documentation practices that most directly prevent avoidable clinical denials.

• Represent the clinical denial function on the cross-functional Denials Prevention Committee, contributing clinical expertise to root cause analyses and prevention initiatives across service lines and facilities.

• Identify systemic clinical denial trends driven by payer behavior, documentation gaps, or authorization failures and escalate to the Sr. Director with supporting data and recommended interventions.

People Leadership and Team Development

• Lead, develop, and retain a team of clinical denial managers, team leads, RN appeal writers, and clinical denial specialists; foster a culture of clinical excellence, accountability, and continuous improvement.

• Define role-specific productivity standards, quality benchmarks, and performance metrics for each level of the clinical denial team; hold regular performance reviews and provide direct, constructive feedback.

• Build structured onboarding and competency development programs for clinical denial staff, including training on payer criteria tools, appeal writing standards, and denial management workflows.

• Identify top performers for advancement and partner with the Sr. Director to support succession planning and career pathway development within the clinical denial function.

Analytics, Reporting, and Process Improvement

• Develop and maintain clinical denial dashboards tracking denial volumes, appeal activity, overturn rates, financial impact, and aging by payer, facility, service line, and denial category.

• Conduct structured root cause analyses on high-volume or high-dollar clinical denial categories; present findings and corrective action recommendations to the Sr. Director and clinical leadership stakeholders.

• Leverage denial data to identify payer-specific patterns, outlier service lines, and prevention opportunities; translate data insights into targeted operational and clinical interventions.

• Contribute to the evaluation and optimization of clinical denial management technology, including denial workflow platforms, AI-assisted appeal tools, and clinical criteria integration within the EHR environment.

• Performs other duties as assigned.

Qualifications

Required

• Bachelor's degree in Nursing, Health Information Management, Healthcare Administration, or a related clinical or health sciences field.

• Active Registered Nurse (RN) licensure required; other advanced clinical licensure will be considered in combination with substantial clinical denial leadership experience.

• Minimum 7 years of experience in healthcare revenue cycle with a primary focus on clinical denials management, utilization review, or case management, including at least 3 years in a management or director-level role.

• Demonstrated track record of leading clinical denial teams and driving measurable improvement in appeal overturn rates and clinical denial write-off reduction across multiple payer types.

• Expert-level knowledge of clinical criteria tools including InterQual and MCG/Milliman Care Guidelines, and the ability to apply them to complex clinical appeal arguments.

• Deep understanding of Medicare, Medicaid, Medicare Advantage, and commercial payer medical necessity standards, coverage policies, and managed care authorization processes.

• Working knowledge of ICD-10-CM/PCS diagnosis and procedure coding concepts, MS-DRG and APR-DRG methodology, and DRG clinical validation as they relate to clinical denial rationale.

• Experience managing physician advisor programs and peer-to-peer review workflows for concurrent and retrospective clinical denials.

• Proficiency with major EHR platforms (Epic, Cerner/Oracle Health, or equivalent) and revenue cycle denial management systems.

• Completion of regulatory/mandatory certifications as required.

• Willingness and ability to travel to client or organizational sites as needed.

Preferred

• Master's degree in Nursing, Healthcare Administration, Health Information Management, or a related field.

• Certified Case Manager (CCM) or Accredited Case Manager (ACM).

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP).

• Certified Revenue Cycle Professional (CRCP) or Certified Revenue Cycle Representative (CRCR).

• Experience in a multi-facility health system or revenue cycle consulting environment managing clinical denial programs across multiple clients or service lines simultaneously.

• Familiarity with AI-assisted clinical appeal platforms, natural language processing tools for denial identification, and analytics platforms such as Tableau or Power BI.

• Experience with post-payment audit defense for clinical denial categories including RAC, MAC, and Medicare Advantage payment integrity reviews.

Physical Demands and Work Environment

• Primarily office or remote-based environment with periodic travel (up to 10-15%) to facilities, payer meetings, clinical stakeholder engagements, or organizational events.

• Prolonged periods of sitting at a desk and working on a computer.

• Ability to communicate clearly and credibly with clinical, operational, and executive stakeholders in person, by phone, and via video conference.