Description
Salary Range: $113,000.00 - $164,000.00
Summary
The Manager of Billing Denials and Appeals is accountable for leading Washington Health's comprehensive strategy to prevent, manage, and overturn payer denials while maximizing reimbursement across all payer classes. This is a high-impact, cross-functional leadership role requiring deep expertise in payer regulations, clinical documentation, and revenue cycle operations.
The Manager partners with patient accounting, coding, clinical documentation improvement (CDI), utilization review, case management, and managed care contracting teams to identify denial trends, execute root cause analysis, and drive systemic process improvements. This role is responsible for setting departmental goals, monitoring performance metrics, educating staff on payer-specific requirements, and ensuring full compliance with federal and state regulations while optimizing cash flow and financial outcomes.
Statement of Accountability
Reports to: Director of Patient Financial Services
Qualifications
• Education
• Licensure
• Work Experience
• Skills/computer/ specific technical
§ Other qualifications, miscellaneous
Specify if qualifications are Required or Preferred
Education
• Bachelor's degree in Nursing, Health Information Management, Healthcare Administration, or a closely related field required.
• Master's degree (MHA, MBA, MSN, or equivalent) strongly preferred.
• RN licensure or coding certification (e.g., CCS, CPC) highly preferred.
Experience
• Minimum of 5 years of progressive hospital revenue cycle experience, with at least 3 years in a denials management, appeals, or utilization review leadership role.
• Demonstrated experience managing teams and leading cross-functional improvement initiatives in a hospital or integrated health system environment.
• In-depth knowledge of payer regulations, reimbursement methodologies (DRG, APC, per diem, fee schedule), CMS guidelines, and commercial payer contract interpretation.
• Hands-on experience with government audit processes (RAC, MAC, OIG) and payer dispute resolution.
• Proven track record of measurably reducing denial rates and improving appeal overturn rates.
Certifications (Preferred)
• Certified Revenue Cycle Professional (CRCP) or Certified Revenue Cycle Representative (CRCR)
• Certified Coding Specialist (CCS) or Certified Professional Coder (CPC)
• Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT)
• Registered Nurse (RN) - if applicable
• Accredited Case Manager (ACM) or Certified Case Manager (CCM) - if applicable
Essential Job Responsibilities
Achieving Results
Key Components: assess, plan, evaluate, demonstrate initiative, quality of work, productivity
The Manager of Billing Denials and Appeals is expected to set clear goals, track measurable outcomes, and hold the team accountable for performance. Success in this role is defined by tangible improvements in denial rates, appeal overturn rates, and revenue recovery.
• Establish and achieve departmental targets for denial rate reduction, appeal overturn rates, and days-to-resolution, reporting progress to revenue cycle leadership quarterly.
• Lead root cause analysis initiatives that result in measurable, sustained decreases in preventable denials across clinical, technical, and administrative categories.
• Drive financial recovery efforts by ensuring high-dollar and complex denials are prioritized, worked, and resolved within payer-defined timelines.
• Monitor team productivity and quality metrics, implementing corrective action plans when performance falls below established benchmarks.
• Deliver documented cost savings and revenue recovery results through successful audit defense and appeal outcomes.
• Set individual and team performance goals aligned with organizational revenue cycle objectives and conduct regular progress reviews.
Demonstrates Skill
Key Components: competency, job knowledge, organizational skills, analytical skill, management of information, employee & patient safety
Technical Expertise
• Expert-level understanding of denial types (clinical necessity, coding, authorization, timely filing, COB) and corresponding appeal strategies.
• Strong command of payer contracts, fee schedules, and reimbursement logic across Medicare, Medicaid, and commercial lines of business.
• Proficiency in hospital billing and revenue cycle systems (Epic, Cerner, Meditech) and payer web portals.
• Familiarity with denial management and workflow automation platforms (e.g., Kodiak, Optum360, Availity).
• Working knowledge of clinical documentation requirements, ICD-10-CM/PCS coding principles, and clinical criteria sets (InterQual, Milliman).
Analytical & Strategic Thinking
• Translates complex denial data into actionable performance improvement initiatives with clear financial impact.
• Builds and presents executive-level reports, dashboards, and business cases to senior leadership and finance committees.
• Identifies systemic vulnerabilities across the revenue cycle and develops multi-disciplinary, sustainable solutions.
• Proficiency in data analysis tools (Excel, Power BI, or comparable platforms) to monitor trends and model financial impact.
Leadership & Communication
• Proven leadership and team-building skills with the ability to motivate staff, manage performance, and drive results in a fast-paced environment.
• Exceptional written communication skills, including drafting persuasive, evidence-based clinical appeal letters.
• Strong verbal communication and presentation skills; comfortable engaging payer representatives, senior executives, and clinical leaders.
• High degree of emotional intelligence with the ability to navigate complex interpersonal dynamics across departments and with external payers.
• Highly organized with strong attention to detail, deadline management, and the ability to manage multiple priorities simultaneously.
Planning & Coordinating
Key Components: delegates, decision making, problem solving, management of resources
This role requires strategic planning and precise coordination across multiple departments and external stakeholders to ensure denial prevention, timely appeals, and audit readiness.
• Develop and maintain an annual denials management work plan with defined goals, milestones, and resource requirements.
• Coordinate cross-departmental denial prevention efforts with coding, HIM, utilization review, case management, CDI, and billing teams through structured meetings and shared reporting.
• Maintain and update denial management and appeals policies and procedures in coordination with compliance, legal, and revenue cycle leadership.
• Plan and prioritize team workload based on denial inventory aging, payer deadlines, and financial impact to ensure no claims are lost to timely filing or appeal windows.
• Organize and lead payer-specific strategy sessions to address high-volume or systemic denial issues and develop targeted action plans.
• Coordinate audit response activities (RAC, MAC, TPE, commercial) across clinical and administrative teams, managing timelines, documentation requests, and submission deadlines.
• Partner with Managed Care Contracting on payer joint operating committee (JOC) preparation, escalation coordination, and follow-up tracking.
•Professionalism
Key Components: dependability, interpersonal skills, teamwork, patient first ethic, customer service, communication skills, punctuality/attendance, receptiveness to criticism, judgment, confidentiality
The Manager of Billing Denials and Appeals is expected to represent Washington Health with the highest standards of professional conduct, integrity, and ethical behavior in all interactions - internal and external.
• Maintain confidentiality of patient, payer, and organizational information in accordance with HIPAA regulations and Washington Health policies at all times.
• Communicate with clarity, respect, and transparency in all interactions with staff, colleagues, payers, and leadership.
• Model accountability by following through on commitments, meeting deadlines, and acknowledging and addressing errors constructively.
• Approach conflict resolution professionally, seeking collaborative solutions while maintaining focus on organizational goals.
• Represent the department with credibility and confidence in payer meetings, executive briefings, and cross-functional forums.
• Maintain professional demeanor and composure in high-pressure situations, including payer disputes, audit responses, and leadership reviews.
• Adhere to Washington Health's Code of Conduct, departmental policies, and all applicable employment standards.
