Job Summary
The Lead Denial Management Specialist serves as the subject matter expert (SME) for denial management and complex revenue cycle operations. This position is responsible for leading denial resolution efforts, maximizing reimbursement, supporting revenue integrity initiatives, and improving revenue cycle performance through data analysis, education, and process improvement.
The Lead Denial Management Specialist partners with providers, operational leaders, coding, billing, clinical departments, and external revenue cycle vendors to identify denial trends, resolve complex reimbursement issues, improve workflows, and ensure compliance with payer requirements and regulatory guidelines. This individual serves as the primary escalation resource for challenging accounts while mentoring team members and promoting best practices across the organization.
ESSENTIAL FUNCTIONS:
- Serve as the primary escalation point for complex insurance denials, reimbursement issues, payer disputes, and patient account concerns.
- Investigate, analyze, and resolve denied, rejected, and underpaid claims while identifying root causes and implementing corrective actions.
- Prepare, submit, and monitor first-level and advanced payer appeals in accordance with payer guidelines and timely filing requirements.
- Review patient accounts, claim submissions, coding, documentation, and charge activity to ensure billing accuracy and maximize reimbursement.
- Conduct comprehensive denial trend analyses and collaborate with operational, coding, clinical, and provider teams to reduce future denials.
- Identify revenue integrity opportunities and recommend workflow improvements that enhance reimbursement and operational efficiency.
- Serve as the subject matter expert on payer policies, reimbursement methodologies, contractual obligations, and denial management best practices.
- Assist with payer negotiations related to non-contracted services, underpayments, and reimbursement discrepancies; escalate unresolved issues as appropriate.
- Monitor denial inventory, aging accounts, and productivity to ensure timely resolution and compliance with organizational performance standards.
- Develop and deliver education and training to providers, clinical staff, revenue cycle personnel, and new employees regarding denial prevention, documentation, billing requirements, and payer updates.
- Collaborate with internal departments and external Revenue Cycle Management partners to improve workflows and resolve complex reimbursement challenges.
- Review and interpret payer communications, policy updates, and reimbursement changes to ensure organizational compliance.
- Monitor and analyze key revenue cycle performance indicators, including denial rates, appeal success rates, reimbursement trends, and collection performance.
- Maintain accurate documentation of account activity and appeal actions within the practice management system.
- Support departmental quality assurance initiatives through account audits and compliance reviews.
- Participate in special projects, system implementations, payer initiatives, and process improvement efforts as assigned.
- Perform other duties as assigned.
Requirements:
Education/Experience:
- Minimum of three (3) years of progressively responsible experience in physician practice revenue cycle management, medical billing, or denial management.
- Experience with payer appeals, reimbursement analysis, and revenue cycle operations required.
- Experience with multi-specialty physician practices preferred
Preferred Qualifications
- Associate or bachelor’s degree in healthcare administration, Business Administration, Finance, or related field.
- Certified Professional Coder (CPC), Certified Professional Biller (CPB), Certified Revenue Cycle Representative (CRCR), or similar preferred certification.
- Experience with ModMed, Epic, Athenahealth, or comparable physician practice management systems.
- Experience supporting revenue cycle process improvement initiatives and operational performance reporting.
Knowledge, Skills and Abilities:
- Knowledge: 3+ years ePM and EHR experience, ModMed knowledge preferred, Microsoft Office, mathematical calculations, understanding of billing requirements on claims and medical terminologies, general knowledge of healthcare insurer reimbursement systems, payer contracts and appeal rights and timely filing requirements of payers. Physician practice revenue cycle operations, insurance billing, reimbursement methodologies, and denial management
- Abilities: Communicate effectively both in written and oral format about clinical information; work independently; exercise judgement and problem solving in investigating denied claims, build positive rapport with colleagues and work with all levels of the organization and third parties to resolves issues as needed
- Skills: Excellent verbal, written and interpersonal communication; proficient in MS Office; excellent organization and time management, high attention to detail
Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Constantly required to talk or hear. Frequently required to stand, walk, and sit; may sit for long durations of time. Frequent use of hands, fingers and arms. Occasionally needs to climb or balance, stoop, kneel, crouch, or crawl. Occasionally lift up to 20 pounds. Constantly required to see; review written material, computer screens & phones with the ability to adjust focus.
Pay: From $25.00 per hour
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Flexible spending account
- Life insurance
- Paid time off
- Vision insurance
Education:
Experience:
- physician practice revenue cycle management: 3 years (Required)
- revenue cycle operation: 3 years (Required)
Ability to Commute:
- Gastonia, NC 28054 (Required)
Work Location: In person
