Team Leader - Clinical Denials

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.