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Insurance Authorization Denial Specialist

Position Summary

The Insurance Authorization Denial Specialist is responsible for reviewing, analyzing, and resolving authorization-related denials for inpatient admissions, with a primary focus on patients admitted through the Emergency Department. This position works closely with Case Management, Utilization Review, ED physicians, hospitalists, and insurance payers to overturn denials by demonstrating that admissions met inpatient clinical criteria under InterQual or MCG guidelines at the time of the admission decision.

The ideal candidate has a strong working knowledge of utilization review, payer medical necessity standards, ED-to-inpatient admission workflows, and the clinical documentation required to support an inpatient level of care.

Essential Duties and Responsibilities

• Review and resolve authorization denials, medical necessity denials, level-of-care downgrades (inpatient to observation), and concurrent review denials issued by commercial, managed care, Medicare Advantage, and Medi-Cal Managed Care payers.
• Analyze ED documentation, H&P, physician orders, and clinical course to determine whether the admission met InterQual or MCG inpatient criteria at the point of admission.
• Prepare and submit timely peer-to-peer requests, reconsiderations, and written clinical appeals citing the specific InterQual or MCG criteria met, supported by source documentation from the medical record.
• Coordinate peer-to-peer reviews between hospitalists, ED physicians, and payer medical directors; track outcomes and follow up on verbal authorizations in writing.
• Partner with Case Management and Utilization Review to identify documentation gaps that contributed to a denial and communicate findings back to ED and hospitalist providers.
• Monitor payer portals, fax queues, and correspondence for adverse determinations, NOMNC notices, and authorization status updates; ensure denials are worked within payer appeal timeframes.
• Track denial reasons, payers, admitting providers, and criteria sets involved; identify recurring patterns (e.g., observation downgrades, missed notification windows, criteria not clearly documented) and report trends to leadership.
• Ensure compliance with payer contract terms, CMS Two-Midnight Rule, Condition Code 44 procedures, and Medi-Cal authorization requirements.
• Maintain accurate documentation of all denial activity, appeal submissions, and outcomes within the hospital's UR and patient accounting systems.
• Support payer audits and respond to requests for additional clinical information.
• Participate in process improvement initiatives aimed at reducing avoidable denials at the front end - including notification of admission, concurrent review timeliness, and physician documentation of inpatient criteria.
• Maintain confidentiality of patient information in accordance with HIPAA.
• Perform other duties as assigned.

Minimum Qualifications

Education

• High school diploma or equivalent required.
• Associate or Bachelor's degree in Nursing, Health Information Management, Healthcare Administration, or related field preferred.

Experience

• Minimum of two (2) years of utilization review, case management, denials management, or payer authorization experience preferred.
• Hospital acute care experience strongly preferred, particularly with ED admissions and observation-versus-inpatient determinations.

Knowledge, Skills, and Abilities

• Working knowledge of InterQual and/or MCG inpatient admission criteria and how to apply them to ED presentations.
• Understanding of payer medical necessity standards, concurrent review, peer-to-peer processes, and the appeal hierarchy across commercial, Medicare Advantage, and Medi-Cal Managed Care lines.
• Familiarity with the CMS Two-Midnight Rule, Condition Code 44, observation status rules, and NOMNC requirements.
• Strong clinical documentation review skills and the ability to translate physician documentation into criteria-based justification.
• Excellent written communication skills, including the ability to draft persuasive clinical appeal letters.
• Ability to prioritize a denial queue against payer appeal deadlines.
• Proficient with EMR systems, payer portals, and UR review platforms.

Preferred Qualifications

• Active LVN or RN license, or InterQual / MCG certification.
• Prior experience writing clinical appeals or representing the hospital in peer-to-peer reviews.
• Experience with Meditech EHR.
• Familiarity with managed Medi-Cal plans serving the Central Valley (e.g., CalViva, Anthem Blue Cross, Health Net).