Specialist, Clinical Appeals

Welcome to Ovation Healthcare!

At Ovation Healthcare, we’ve been making local healthcare better for more than 40 years. Our mission is to strengthen independent community healthcare. We provide independent hospitals and health systems with the support, guidance and tech-enabled shared services needed to remain strong and viable. With a strong sense of purpose and commitment to operating excellence, we help rural healthcare providers fulfill their missions.

The Ovation Healthcare difference is the extraordinary combination of operations experience and consulting guidance that fulfills our mission of creating a sustainable future for healthcare organizations. Ovation Healthcare's vision is to be a dynamic, integrated professional services company delivering innovative and executable solutions through experience and thought leadership, while valuing trust, respect, and customer focused behavior.

We’re looking for talented, motivated professionals with a desire to help independent hospitals thrive. Working with Ovation Healthcare you will have the opportunity to collaborate with highly skilled subject matter specialists and operations executives, in a collegial atmosphere of professionalism and teamwork.

Ovation Healthcare's corporate headquarters is located in Brentwood, TN. For more information, visit https://ovationhc.com.

Summary:
The Clinical Appeals Specialist is a key clinical expert within the new Revenue Recovery Team at Amplify RCM. This role is dedicated to maximizing revenue recovery for our Insource clients by overturning complex clinical denials. The ideal candidate is a Registered Nurse (RN) with strong analytical skills who will conduct in-depth medical record reviews, construct compelling, evidence-based arguments, and manage the clinical appeals process from start to finish.

Leveraging our advanced technology platform, Health Innovas "Pulse," and a specialized AI partner, you will be instrumental in securing reimbursement for medically necessary care, identifying denial trends, and collaborating with a multidisciplinary team to protect our clients' financial health. This is a critical role that directly contributes to our clients' success and the growth of this new, high-impact service line.

• Clinical Denial Review and Analysis:

  • Perform comprehensive reviews of denied claims, focusing on clinical issues such as medical necessity, level of care, non-covered services, and authorization-related denials.

  • Conduct thorough analysis of patient medical records, payer medical policies, and relevant medical necessity criteria (e.g., InterQual, Milliman) to build a robust clinical case for appeal.

  • Identify gaps in clinical documentation and collaborate with other team members to gather the necessary supporting evidence for a successful appeal.

• Appeal Generation and Submission:

  • Independently write professional, persuasive appeal letters that present a compelling clinical argument for payment.

  • Leverage generative AI tools to assist in drafting initial appeal letters, increasing efficiency and allowing focus on the most complex cases.

  • Ensure all appeals are submitted accurately, within payer-specific timelines, and tracked through to final resolution in the Pulse platform.

• Collaboration and Process Improvement:

  • Work closely with the Payer Contract Specialist, Certified Coders, and Revenue Recovery Specialists to ensure a holistic and coordinated approach to each appeal.

  • Identify and report emerging denial trends to team leadership to support root cause analysis and the development of denial prevention strategies.

  • Assist in creating and maintaining standardized appeal letter templates for various denial types and payers to improve team efficiency.

KNOWLEDGE, SKILLS, AND ABILITIES:

•  Strong clinical acumen with the ability to critically analyze medical records and justify the medical necessity of services rendered.

• Exceptional written communication skills, with the ability to craft clear, concise, and persuasive arguments.

• Technologically proficient and comfortable learning and mastering new software; experience with EHR/EMR systems is essential.

• Comfortable navigating and troubleshooting various applications, including Microsoft Office Suite, data management systems, and virtual collaboration tools.

• Highly organized, self-motivated, and able to work independently to manage a caseload and meet deadlines.

• Familiarity with medical billing, coding principles (ICD-10, CPT), and payer reimbursement methodologies.

WORK EXPERIENCE, EDUCATION AND CERTIFICATIONS:

Active and unrestricted Registered Nurse (RN) license.

Bachelor of Science in Nursing (BSN) preferred.

Previous experience in denial management or clinical appeals role.

Minimum of 2-3 years of clinical experience in a hospital or healthcare setting. Experience in Case Management, Utilization Review, or Clinical Documentation Improvement (CDI) is highly desirable.

Technologically proficient and comfortable learning and mastering new software; experience with EHR/EMR systems is essential.

WORKING CONDITIONS AND PHYSICAL REQUIREMENTS:

• 100% Remote

• Reliable high-speed internet connection is required for all remote/hybrid positions.

• Must have access to stable Wi-Fi with sufficient bandwidth to support video conferencing, cloud-based tools, and other online work-related activities.

• A HIPAA-compliant work environment is required, including a secure workspace free from unauthorized access or interruptions, no use of public Wi-Fi unless connected through a secure company-provided VPN, and compliance with all applicable HIPAA privacy and security regulations.