Job Requirements
Supervises the Denials Management Specialist team responsible for the intake, investigation, and documentation of medical necessity, technical, and audit-related denials. Reviews remittance advice denials and audit requests for accuracy and appropriateness and gathers required information to resolve assigned cases. Utilizes designated work queues to reduce outstanding account balances and minimize uncompensated care. Collaborates with vendors, insurance carriers, and internal departments to monitor appeal status and ensure timely and accurate processing. Operates under moderate supervision while supporting departmental performance goals.
Primary Responsibilities
The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job responsibilities performed.
Supervise the review, investigation, and resolution of assigned denial cases using designated work queues to reduce outstanding account balances and minimize uncompensated care.- Oversee complex, high-priority accounts and special projects, ensuring timely and accurate resolution in alignment with departmental goals.
- Ensure accurate interpretation of insurance policies, payer guidelines, and Explanation of Benefits (EOBs), and guide appropriate corrective actions including appeals, adjustments, resubmissions, and eligibility verifications.
- Monitor remittance advice denials and audit requests for accuracy and appropriateness, ensuring all supporting documentation is complete and compliant.
- Maintain current knowledge of reimbursement methodologies, financial guidelines, and federal and state payer regulations, and apply this knowledge to team oversight and decision-making.
- Collaborate with insurance carriers, payer representatives, vendors, and internal departments to monitor appeal status and facilitate timely, accurate processing of denial cases.
- Conduct regular quality assurance (QA) reviews to ensure denial-related activities are documented accurately, timely, and in accordance with established standards throughout the appeals process.
- Ensure proper handling of audit requests, including the preparation of itemized bills and maintenance of detailed audit logs and reporting.
- Supervise root cause analysis of denials to identify trends and support the development of corrective and preventive actions.
- Ensure appropriate escalation and referral of denial cases to clinical teams or external denial vendors based on case evaluation.
- Promote effective communication and collaboration across Revenue Cycle departments, hospital leadership, payers, and vendors to support denial resolution and operational efficiency.
- Share insights, trends, and performance data with team members and leadership to improve denial accuracy, identify process improvement opportunities, and support clinical appeal strategies.
- Develop and maintain reference materials, including reimbursement guidelines, payer policies, and regulatory requirements, to support team performance and consistency.
- Perform all other duties as assigned.
Work Experience
- High school diploma or equivalent (GED).
- Three (3) years of experience in denial and appeals processing, utilization review, collections, or medical administration within a healthcare or clinical setting.
Education & Experience - Preferred
- Associate’s degree in Business Administration, Healthcare Administration or a related field.
- Four (4) years of direct experience in denial and appeals processing.
Knowledge, Skills, & Abilities
- Knowledge of applicable federal and state regulations and payer requirements (e.g., CMS, HSCRC, Medicare, Medicaid, and commercial payers).
- Knowledge of healthcare billing and coding standards, including CPT, ICD-10, and HCPCS.
- Knowledge of denial and appeals processes, including payer-specific policies and requirements across government and commercial plans.
- Skill in interpreting Explanation of Benefits (EOBs), remittance advice, and payer correspondence to determine denial causes and appropriate resolution actions.
- Skill in preparing appeals and supporting documentation, including medical records, itemized statements, and payer-required forms.
- Skill in analyzing denials, performing root cause analysis, and identifying trends to support resolution and process improvement.
- Ability to research, evaluate, and resolve medical necessity and technical denials in a timely manner.
- Ability to manage multiple priorities, meet deadlines, and operate effectively in a high-volume, fast-paced environment.
- Ability to communicate clearly and effectively with clinical and non-clinical stakeholders, including internal teams, payers, and vendors.
- Skill in building collaborative working relationships and using Microsoft Office tools (Excel, Word, Outlook, PowerPoint) to support reporting and workflow management.
