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Sr. Clinical Denials Prevention Analyst (Remote)

Stanford Health Care -
Sacramento, CA

Apply Now

Job Details

Full-time
$66.52 - $88.14 an hour
10 days ago

Qualifications

Nursing
Defect resolution root cause analysis
Medicare
Utilization review
RN License
CMS
Coding for hospital billing
Medical claim appeals
CMS regulatory compliance
Medicare regulations
InterQual
Utilization management
Health policy
Resource utilization in healthcare
Medical insurance appeals management
Centers for Medicare & Medicaid Services (CMS) billing regulations
Medicaid regulations
Medicaid
Milliman Care Guidelines (MCG Health)
Acute care experience
Epic
Clinical documentation standards
Cross-functional communication
Medical record review for billing accuracy
Nursing

Full Job Description

1.0 FTE Full time Day - 08 Hour R2657990 Remote USA 108530009 Rev Cycle Denials Finance & Revenue Cycle

If you're ready to be part of our legacy of hope and innovation, we encourage you to take the first step and explore our current job openings. Your best is waiting to be discovered.

Day - 08 Hour (United States of America)

This is a Stanford Health Care job.

A Brief Overview
The Senior Clinical Denials Prevention Analyst serves as a clinical subject matter expert focused on reducing clinically related, documentation-related, and clinical operations-related denials through data and account analysis. The role partners across clinical, operational, revenue cycle, and payer-facing teams to identify patterns, assess root causes, and recommend improvements across the care-to-claim continuum, both before and after claim submission. The analyst proactively engages stakeholders to develop data-informed remediation strategies, support workflow optimization, and establish upstream practices that mitigate avoidable denials and accelerate resolution of those that cannot be prevented. Using a range of analytics and financial analysis, the position monitors performance, uncovers systemic issues, and translates insights into practical, sustainable solutions. Through continuous improvement initiatives and targeted education, this role strengthens revenue integrity and enhances overall denial and revenue performance.

Locations
Stanford Health Care

What you will do

Analyze denial and write-off data across payers to identify patterns, root causes, and prevention opportunities across clinical, documentation, coding, and charging processes for both pre-bill and post-bill denials.
Conduct denial reviews to identify gaps in documentation, UM or revenue cycle workflows, coding, and billing rules and collaborate with UM, CDI, coding, and case managers to address gaps and implement corrective actions.
Lead cross-functional root-cause analyses with UM, CDI, HIM, Coding, Case Management, Billing, and payer teams to design and implement remediation strategies.
Help develop and implement denial prevention strategies, workflows, and playbooks and monitor their effectiveness through regular KPI reporting.
Monitor payer policy changes, national guidelines, and CMS/Medicare/Medicaid updates to ensure compliance and timely adjustment of practices.
Maintain denial dashboards, action plans, and performance reports for leadership review.
Prepare summary findings of analysis for department leadership; maintain clear documentation of analyses and outcomes; escalate systemic risks and barriers as appropriate.
Provide root cause analysis and support the mitigation of denial and denial write-off trends.
Perform standard to moderately complex financial and operational analyses to quantify impact, inform decisions, and track benefits realization.

Education Qualifications

Bachelor’s Degree (BSN) is highly preferred. Diploma or Associate’s Degree in Nursing accepted when accompanied by strong demonstrated competencies and significant experience.

Experience Qualifications

Minimum of five (5) years in nursing with a minimum of two (2) years’ experience as Utilization Management Nurse in an acute care setting required. UM or CM leadership experience preferred.
Experience and working knowledge of 2 Midnight, Milliman, and InterQual Guidelines required.
Minimum of two (2) years of experience in denial prevention, denial recovery, clinical appeals, or related denial-management responsibilities within a healthcare setting.
Experience with Epic HB and PB highly desirable

Required Knowledge, Skills and Abilities

Strong understanding of ICD-10-CM/PCS, CPT/HCPCS coding, and medical necessity guidelines.
Strong understanding of 2 Midnight, Milliman, and InterQual Guidelines
Familiarity with payer policies, reimbursement methodologies, and CMS guidelines (including Medicare/Medicaid rules) and common commercial payer practices.
Knowledge of CDI concepts, documentation standards, and revenue cycle processes.
Ability to apply high-level problem-solving skills to perform root cause analysis on denied accounts and develop actionable remediation strategies.
Ability to manage, organize, prioritize, multi-task and adapt to changing priorities.
Ability to communicate effectively in written and verbal formats including summarizing data, presenting results.
Ability to establish and maintain effective working relationships.
Working knowledge of hospital and physician revenue cycle systems, including Epic.

Licenses and Certifications

CA Registered Nurse - Valid license as a Registered Nurse issued by the California Board of Registered Nursing (BRN). Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying. required Upon Hire
CRCR - Certified Revenue Cycle Representative preferred

These principles apply to ALL employees:

SHC Commitment to Providing an Exceptional Patient & Family Experience

Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.

You will do this by executing against our three experience pillars, from the patient and family’s perspective:

Know Me: Anticipate my needs and status to deliver effective care
Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
Coordinate for Me: Own the complexity of my care through coordination

Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

Base Pay Scale: Generally starting at $66.52 - $88.14 per hour

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.

Apply Now

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