The
Manager, Denials & Appeals, RCM is responsible for leading denial management, appeal strategy, and reimbursement recovery operations. This role focuses on improving overturn rates, reducing denial volumes, accelerating AR resolution, and maximizing reimbursement outcomes.
The Manager partners closely with Market Access, Billing Operations, Clinical Operations, and Finance to identify denial root causes, implement corrective actions, and ensure compliance with payer requirements and regulatory standards.
KEY RESPONSIBILITIESDenial Management & Appeals Oversight- Lead daily operations for denial management, appeals, and reimbursement recovery workflows.
- Oversee timely submission of appeals, ensuring accuracy, completeness, and alignment to 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, 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.
QUALIFICATIONSRequired- 6+ years of progressive healthcare RCM experience, including denials, appeals and reimbursement recovery.
- 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 & Root Cause Analysis
- Appeals Strategy & Payer Negotiation
- Data Analytics & KPI Management
- Operational Leadership
- Cross-Functional Collaboration
PHYSICAL DEMANDS AND WORK ENVIRONMENT- Location: Remote
- Frequently required to sit; regularly required to talk/hear; regular use of computer and standard office equipment.
- Office environment with regular interaction across clinical, operational, and commercial stakeholders.
- Travel Requirements: Occasional travel may be required, such as onsite meetings, vendor or payer sessions, or operational reviews.
