Clinical Denials Specialist​/Utilization Management

Clinical Denials Specialist / Utilization Management

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.

ERISA Recovery is a fast‑growing company based in Dallas, TX, specialising 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.

• Review clinical documentation and denial letters to assess the reason for denial.
• Conduct thorough clinical reviews for inpatient and outpatient cases.
• Utilize Inter Qual, 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.

• Registered Nurse (RN) – active license required.
• Minimum of 3–5 years of clinical experience in Clinical Review and Inpatient Case Management, and Emergency Room (ER) Case Management.
• Strong experience with medical necessity criteria tools:
  Inter Qual, 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.

• Experience with denial analytics and reporting tools.
• Knowledge of Medicare Advantage and Medicaid Managed Care regulations.

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

Schedule
: 8‑hour shift.

Ability to Relocate
:
Plano, TX 75093 – relocate before starting work (Required).

ERISA Recovery is an Equal Opportunity Employer.