Team Leader - Clinical Denials

About this role

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.