Clinical Government Audit Analyst and Appeal Specialist

Company: Stamford American International Hospital
Location: San Diego
Posted on: January 2, 2026

Job Description:

Clinical Government Audit Analyst and Appeal Specialist II plays a critical role in the Revenue Cycle Denials Management Department by managing and resolving clinical appeals related to government audits and denials. This position requires strong clinical acumen, a strong understanding and application of clinical documentation standards, coding, and regulatory requirements, as well as excellent analytical and communication skills. The Clinical Government Audit Analyst and Appeals Specialist II will collaborate with clinical staff, coding professionals, and external stakeholders to ensure timely and accurate resolution of appeals, ultimately contributing to the financial health of the organization. There are three (3) career banded levels within the Denials Management family. Positions are flexibly staffed at any of the three levels and progression from one level to the next higher level depends, first, on the need for a position at the higher level; second, on the nature, scope and complexity of the duties assigned; and third, on an employees demonstrated and applied knowledge, skills and abilities and professional behaviors. Clinical Government Audit Analyst and Appeal Specialist II is the full proficiency or journey level of the Clinical Government Audit Analyst and Appeal Job Family where employees are responsible for independently performing the full range of duties of moderate difficulty and complexity as outlined under the Job Duties Essential Functions. Performs audits and appeals of limited scope with greater independence. May be responsible for determining audit scope, appeal strategies, and key controls. Locations Stanford Health Care What you will do Adheres to Stanford Health Care’s organization competencies and Code of Conduct. Denial Analysis: Conduct thorough analyses of denials, evaluating the appropriateness of medical services and procedures. Ensure accurate coding with ICD, HCPCS, CPT codes, as well as APC and DRG assignments, while identifying instances of overpayments and underpayments. Proficiency in healthcare claims analysis, including the ability to review, interpret, and evaluate claims data to identify trends, discrepancies, and opportunities for improvement. Maintains accurate records of appeals and denials for tracking and reporting purposes. Appeal Letter Drafting: Independently compose professional and comprehensive appeal letters to payors after a detailed review of medical records. Ensure compliance with Medicare, Medicaid, third-party guidelines, Local Coverage Determinations (LCD), National Coverage Determinations (NCD), clinical documentation, coding guidelines, and payor policies to effectively challenge denials. Appeal Strategies Development: Create comprehensive appeal strategies based on relevant guidelines and documentation to effectively address denials. Submission of Appeals: Draft and submit detailed appeal letters along with supporting documentation, ensuring adherence to regulatory requirements and payor guidelines. Appealability Scoring: Provide a thoughtful appealability score for each denial under review, assessing the likelihood of a successful appeal. Proofreading and Editing: Review and edit appeals for clarity and accuracy prior to submission to ensure high-quality presentation. Audit Response: Ensuring the medical record documentation supports medical necessity and all services billed. Work closely with clinical teams, coding specialists, physicians and other departments to gather necessary information and clarify clinical documentation to support appeals. Collaboration with Management: Identify and escalate denial patterns to the Manager of Government Audits and Appeals, providing detailed information for follow-up and resolution. Deadline Management: Complete all assigned tasks by established deadlines and communicate proactively with the Manager of Government Audit and Appeal regarding any potential barriers to timely completion. Regulatory Compliance Stay updated on changes in healthcare regulations, payor policies, and industry best practices related to clinical appeals and denials management. Evaluate internal controls related to documentation, coding, charging, and billing practices to ensure compliance. Government Audit and Appeals Program Development: Actively participate in developing appeal templates, audit tools, goals, policies, and procedures for the Denials Management Department. Serve as a subject matter expert on billing and coding regulations and collaborate with team members on joint projects to enhance the framework. Education Qualifications Bachelor’s degree in nursing from an accredited college or university. Required Experience Qualifications Minimum two (2) years of progressive denials and appeals experience. Required Required Knowledge, Skills and Abilities Ability to manage, organize, prioritize, multi-task, and adapt to changing priorities while meeting deadlines. Ability to communicate effective in written and verbal formats including summarizing data and presenting results. Extensive writing capabilities and efficiencies. Ability to influence outcomes through convincing arguments supported by data. Ability to apply critical thinking skills to identify patterns and trends. Ability to mediate and solve complex work problems and issues. Ability to effectively facilitate work groups to successful outcomes. Knowledge of medical and insurance terminology, MS-DRG, APR-DRG, CPT, ICD coding structures, and billing forms (UB, 1500). Experience with coding, clinical validation, and medical necessity for inpatient stays. Knowledge of third-party payor rules and regulations. Knowledge of local, state, and federal healthcare regulations. Knowledge of detailed healthcare corporate compliance functions and audits to identify and eliminate waste, fraud and abuse, and inefficiencies in conformance with prescribed laws, regulations, and standards, reach independent decisions and logical conclusions, and prepare reports of findings and recommendations. Ability to model and demonstrate consistently high standards of professional ethics, integrity, and trust. Ability to maintain confidentiality of sensitive information. Ability to maintain competency and up-to-date knowledge of healthcare compliance, billing and coding requirements, practices, and trends. Proficiency in computer systems, specifically EPIC and 3M. Proficiency in computer software, including Microsoft Word, Excel, and Power Point. Ability to adapt to changing priorities and shifts in denials and appeals activity while maintaining high standards of accuracy and compliance. Demonstrated flexibility in responding to new challenges and evolving healthcare regulations. Licenses and Certifications CCA - Certified Coding Assoc required within 180 Days or CCS - Certified Coding Specialist required within 180 Days or COC - Certified Outpatient Coder required within 180 Days or CDIP – Clinical Documentation Improvement Practitioner required within 180 Days or CCDS - Cert Clinical Document Spec required within 180 Days RN - Registered Nurse - State Licensure And/Or Compact State Licensure preferred . Physical Demands and Work Conditions Blood Borne Pathogens Category III - Tasks that involve NO exposure to blood, body fluids or tissues, and Category I tasks that are not a condition of employment 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 $62.75 - $83.16 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.

Keywords: Stamford American International Hospital, San Diego , Clinical Government Audit Analyst and Appeal Specialist, Healthcare , San Diego, California