Overview
This role is responsible for leading denial management, appeal strategy, and reimbursement recovery operations within revenue cycle management (RCM). The focus is on improving overturn rates, reducing denial volumes, accelerating accounts receivable (AR) resolution, and maximizing reimbursement outcomes.
The manager will collaborate closely with Market Access, Billing Operations, Clinical Operations, and Finance teams to identify root causes of denials, implement corrective actions, and ensure compliance with payer requirements and regulatory standards.
Responsibilities
Denial Management & Appeals Oversight
- Lead daily operations for denial management, appeals, and reimbursement recovery workflows.
- Oversee timely submission of appeals, ensuring accuracy, completeness, and alignment with payer requirements.
- Manage high-value and complex denial escalations, including payer disputes and medical necessity rejections.
Denial Analytics & Prevention
- Analyze denial trends, payer behaviors, and root causes to identify systemic issues.
- Develop and implement denial prevention strategies across front-end, billing, and clinical workflows.
- Partner with Market Access to address payer policy gaps and recurring denial drivers.
Reimbursement Recovery & AR Optimization
- Drive recovery of underpayments, denied claims, and aged receivables.
- Monitor AR performance, turnaround times, and resolution rates to ensure timely reimbursement.
- Oversee processes for discrepancies, payment variances, and unresolved claims.
Appeal Strategy & Execution
- Establish standardized appeal templates, documentation standards, and supporting evidence requirements.
- Ensure appeals are supported by clinical documentation, payer policy alignment, and coding accuracy.
- Collaborate with Clinical and Coding teams to strengthen appeal defensibility.
Quality, Compliance & Audit
- Ensure adherence to payer guidelines, CMS regulations, and internal compliance standards.
- Conduct quality audits on denial handling and appeals submissions.
- Maintain audit-ready documentation and establish controls for compliance assurance.
Team Leadership & Performance Management
- Lead, coach, and develop denial and appeals staff.
- Monitor productivity, quality, and turnaround KPIs; drive performance improvements.
- Establish training, standard operating procedures (SOPs), and best practices for consistency and scalability.
Reporting & Continuous Improvement
- Identify opportunities to improve workflows, reduce manual effort, and increase automation.
- Collaborate cross-functionally to resolve upstream issues impacting denial volume.
Qualifications
Required
- Minimum 6 years of progressive healthcare RCM experience, including denials, appeals, and reimbursement recovery.
- At least 2 years of leadership experience managing denial or AR follow-up teams.
- Strong expertise in payer appeals processes, denial codes, and reimbursement methodologies.
Preferred
- Experience in diagnostic laboratory, genetics, molecular diagnostics, or precision medicine.
- Strong familiarity with payer medical policies and reimbursement methodologies.
- Familiarity with Xifin, Quadax, or Telcor RCM platforms.
Competencies
- Denial prevention and root cause analysis
- Appeals strategy and payer negotiation
- Data analytics and KPI management
- Operational leadership
- Cross-functional collaboration
Physical Demands and Work Environment
- Location: Remote
- Frequently required to sit; regularly required to talk and hear; regular use of computer and standard office equipment.
- Office environment with regular interaction across clinical, operational, and commercial stakeholders.
- Occasional travel may be required for onsite meetings, vendor or payer sessions, or operational reviews.
Equal Employment Opportunity
The employer is an equal opportunity organization committed to fostering an inclusive and diverse workplace. Applicants from all backgrounds are encouraged to apply. There is no discrimination based on race, color, religion, national origin, sex, sexual orientation, gender identity, age, veteran status, disability, genetic information, pregnancy, childbirth, or any other status protected by applicable federal, state, or local law.
Accommodations are available during the application process upon request.