Work setup: ONSITE / BGC, Taguig within 6 months then transfer to Bridgetowne, QC
Work schedule: Nightshift
The Team Lead – Clinical Denials provides operational and clinical leadership to a team of Clinical Denials Specialists supporting U.S. healthcare clients. The role oversees daily workflow, productivity, quality, employee performance, complex denial escalations, and denial prevention activities.
The Team Lead serves as a subject-matter resource for medical necessity, clinical documentation, DRG, level of care, coding, reimbursement, and U.S. payer requirements.
Qualifications:
Required
- Bachelor’s degree in nursing, Healthcare Administration, Health Information Management, or related field.
- Valid Philippine RN license/PRC registration for RN-required positions.
- 3 to 5 years of experience in U.S. healthcare RCM, clinical denials, CDI, utilization management, claims, or appeals.
- Demonstrated experience leading or mentoring healthcare teams, preferably 20+ employees.
- Strong knowledge of medical necessity, DRG, level of care, clinical documentation, coding, reimbursement, and U.S. payer policies.
- Strong communication, analytical, problem-solving, and people-management skills.
- Willingness to work U.S.-aligned shifts as required.
Preferred
- CDAS or equivalent denial management credential.
- CCDS/CDIP or equivalent CDI certification.
- CCS/CPC or equivalent coding certification.
- Experience with Epic and U.S. payer portals.
- Experience managing denial inventory and performance dashboards.
Duties and Responsibilities
Team Leadership & Operations
- Leads daily activities of a team of 20+ Clinical Denials Specialists.
- Assigns and prioritizes denial inventory based on complexity, aging, financial impact, and payer requirements.
- Monitors productivity, quality, turnaround time, and appeal outcomes.
- Provides coaching, mentoring, and performance feedback.
- Supports onboarding and training of team members.
- Escalates operational, clinical, payer, and client issues to management.
Denial Review & Appeals
- Reviews complex and high-dollar clinical denials.
- Provides guidance on medical necessity, DRG, level of care, clinical validation, documentation, and coding-related denials.
- Reviews appeal letters for accuracy, completeness, and supporting evidence.
- Supports interpretation of U.S. payer policies and reimbursement requirements.
- Collaborates with CDI, HIM, Coding, Utilization Management, and other RCM stakeholders.
Quality & Denial Prevention
- Partners with QA to address quality findings and performance gaps.
- Identifies recurring denial trends and opportunities for prevention.
- Supports root-cause analysis and process improvement initiatives.
- Ensures work complies with client requirements, payer policies, privacy, and organizational standards.
Reporting & Stakeholder Management
- Reviews team performance reports and KPIs.
- Communicates trends, risks, and action plans to management.
- Supports client and internal meetings as required.
- Maintains effective communication with U.S.-based stakeholders.