QA - Clinical Denials

Work setup: ONSITE / BGC, Taguig within 6 months then transfer to Bridgetowne, QC

Work schedule: Nightshift

The QA – Clinical Denials is responsible for conducting quality audits of clinical denial reviews, appeal preparation, documentation, coding validation, and denial management activities to ensure accuracy, compliance, consistency, and adherence to client and payer requirements.

This role evaluates the quality of work performed by Clinical Denials Specialists, identifies errors and opportunities for improvement, provides actionable feedback, and supports continuous improvement of clinical denial processes. The QA is expected to apply strong clinical, coding, reimbursement, and documentation knowledge while maintaining a high level of attention to detail.

The role works closely with Clinical Denials Specialists, Team Leads, Managers, CDI, HIM, Coding, and other revenue cycle stakeholders to improve appeal quality, reduce avoidable errors, and strengthen denial recovery outcomes.

Qualifications

Required

• Bachelor's degree in Nursing, Healthcare Administration, Health Information Management, or related healthcare field.
• Active RN license or applicable clinical credential.
• Minimum 2 to 3 years of healthcare experience in clinical denials, CDI, utilization management, coding, RCM, claims, appeals, or related areas.
• Experience reviewing medical records and clinical documentation.
• Strong knowledge of medical terminology, clinical documentation, coding principles, reimbursement, and payer requirements.
• Strong analytical and problem-solving skills.
• Excellent written and verbal communication skills.
• Strong attention to detail and ability to identify discrepancies.
• Ability to work independently while meeting productivity and quality expectations.

Preferred

• Experience in clinical denials or denial QA.
• CDAS or equivalent denial management credential.
• CCDS, CDIP, or equivalent CDI credential.
• Coding certification such as CCS, CPC, or equivalent.
• Experience with inpatient DRG, medical necessity, clinical validation, and level-of-care reviews.
• Experience with Epic or other EHR systems.
• Experience with payer denial management portals.
• Experience using QA scorecards, audit tools, and reporting dashboards.

Duties and Responsibilities

Quality Assurance & Auditing

• Conducts routine and targeted quality audits of clinical denial reviews and appeals.
• Reviews denied claims, medical records, billing information, payer correspondence, and appeal documentation.
• Evaluates accuracy of denial identification, clinical analysis, coding validation, and appeal rationale.
• Validates that appeal arguments are supported by medical records, clinical documentation, coding guidelines, payer policies, and applicable reimbursement requirements.
• Reviews clinical denial cases for medical necessity, clinical validation, DRG, level-of-care, documentation, coding, and other denial categories.
• Identifies critical, major, and minor quality errors based on established QA standards.
• Ensures appeals are complete, accurate, timely, and appropriately supported.
• Validates appropriate use of clinical terminology, coding concepts, payer requirements, and regulatory guidance.
• Performs random, targeted, and focused audits based on business requirements and identified risk areas.

Quality Scoring & Reporting

• Applies standardized QA scorecards and audit methodologies consistently.
• Documents audit findings accurately and objectively.
• Maintains QA records, audit results, error classifications, and supporting evidence.
• Identifies recurring quality issues and trends.
• Prepares individual and team-level quality reports.
• Tracks quality performance against established targets.
• Escalates significant quality, compliance, or clinical concerns to the appropriate leadership.

Feedback & Coaching

• Provides timely and constructive feedback to Clinical Denials Specialists.
• Explains identified errors and appropriate corrective actions.
• Partners with Team Leads to support coaching and remediation.
• Identifies training opportunities based on audit findings.
• Participates in calibration sessions to promote consistency among reviewers and QA staff.
• Supports development and maintenance of QA reference materials and job aids.

Compliance & Process Improvement

• Ensures reviewed work follows client policies, payer requirements, regulatory standards, and organizational procedures.
• Monitors changes in payer policies, coding guidelines, reimbursement requirements, and regulatory expectations that may affect QA standards.
• Identifies process gaps that contribute to quality issues or denial leakage.
• Recommends process improvements based on audit findings.
• Participates in denial prevention and quality improvement initiatives.
• Supports root-cause analysis of recurring errors.

Collaboration

• Collaborates with Clinical Denials Specialists, Team Leads, Managers, CDI, HIM, Coding, and other revenue cycle teams.
• Participates in QA and denial management meetings.
• Provides subject-matter input on complex or disputed audit findings.
• Supports client-specific quality requirements and audit requests.
• Performs other duties as assigned.