Clinical Denials Specialist / Utilization Management

Job Summary

We are seeking a highly skilled and experienced Clinical Denials Specialist with a strong background in nursing (RN) and a deep understanding of medical necessity reviews and utilization management. In this role, you will work closely with internal case management teams, insurance providers, and clinical departments to analyze denied claims, prepare appeals, and ensure medical necessity documentation aligns with payer requirements.

About Us: ERISA 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. Our collaborative and innovative team offers an extraordinary opportunity for career growth in the ever-evolving revenue cycle industry. If you’re ready to advance your career with a company that values passion, precision, and teamwork, we want to meet you.

Key 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.

Qualifications

• Registered Nurse (RN) – active license required.
• Minimum of 3-5 years of clinical experience in:

-Utilization Management (UM)

-Clinical Review and Inpatient Case Management

-Emergency Room (ER) Case Management

• Strong experience with:

-Medical necessity criteria tools: InterQual, MCG/Milliman, McKesson Review

-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 Skills

• Case Management Certification (e.g., CCM) a plus.
• Experience with denial analytics and reporting tools.
• Knowledge of Medicare Advantage and Medicaid Managed Care regulations.

Why Join Us?

• Work in a mission-driven environment focused on improving healthcare access and reimbursement.
• Collaborate with a dynamic team of healthcare professionals and revenue cycle experts.
• Competitive compensation and benefits package.
• Opportunities for ongoing training and professional development.

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance
• Paid lunches

Schedule:

• 8 hour shift

Ability to Commute:

• Plano, TX 75093 (Required)

Ability to Relocate:

• Plano, TX 75093: Relocate before starting work (Required)

Work Location: In person

ERISA Recovery is an Equal Opportunity Employer