Manager, Denials Operations

🕒 Junho 5

🇺🇸 Estados Unidos – Remoto (EUA)

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

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Healthrise

SiteLinkedInTodas as Vagas

51 - 200 funcionários

⚕️ Seguro de Saúde

☁️ SaaS

Healthcare Insurance • Consulting • SaaS

A Healthrise é uma empresa dedicada a fornecer soluções completas de saúde, com foco em gestão de ciclo de receita, serviços de prontuário eletrônico (EHR) e consultoria estratégica. Com mais de uma década de experiência, a Healthrise auxilia sistemas de saúde em todo o país a alcançar sucesso operacional e financeiro através de estratégias personalizadas. Sua equipe de especialistas faz parceria com organizações de saúde para enfrentar desafios operacionais complexos e aumentar a eficiência, garantindo que os resultados financeiros e de atendimento ao paciente sejam otimizados.

Descrição

• Responsible for day-to-day supervisory oversight and operational execution of technical and coding denial management functions within the Revenue Cycle department. • Lead a team of denial specialists and coordinators focused on resolving technical and coding-related claim denials across all payer types, facilities, and service lines. • Manage daily denial work queues for technical and coding denial categories, ensuring cases are assigned, prioritized by financial impact and deadline risk, and resolved within payer-required timelines. • Monitor team workload, capacity, and throughput on a daily and weekly basis; adjust case assignments and staffing allocation to prevent missed filing deadlines. • Serve as the first-line escalation point for complex technical and coding denial cases that require manager-level review, payer contact, or cross-functional coordination. • Track and report weekly team performance to the Director including denial volumes, appeal activity, resolution rates, write-off risk, and aging by payer, denial code, and category. • Identify systemic denial patterns or payer behavior trends in the queue and escalate to the Director with root cause analysis and recommended corrective actions. • Oversee resolution of technical denials including timely filing, prior authorization, eligibility, coordination of benefits, duplicate billing, medical records requests, and credentialing-related claim rejections. • Review and approve appeal submissions for high-dollar or complex technical denials prior to filing, ensuring accuracy, completeness, and appropriate supporting documentation. • Partner with Patient Access, Provider Enrollment, Utilization Management, and Billing to trace technical denial root causes back to the point of origin and drive sustainable upstream corrections. • Conduct structured root cause analyses on high-volume technical and coding denial categories; present findings and corrective action plans to the Director with supporting denial data.

🎯 Requisitos

• Bachelor's degree in Health Information Management, Healthcare Administration, Business, or a related field; or an equivalent combination of education and experience. • Minimum 5 years of experience in healthcare revenue cycle with a focus on denials management, claims resolution, or billing operations, including at least 2 years in a lead, supervisory, or management role. • Demonstrated experience managing technical and coding denial queues across Medicare, Medicaid, Medicare Advantage, and commercial payer types. • Working knowledge of ICD-10-CM/PCS, CPT, and HCPCS coding systems and their relationship to claim adjudication, reimbursement, and coding-related denial rationale. • Solid understanding of Medicare and Medicaid billing regulations, managed care authorization requirements, payer contract terms, and timely filing rules across major payer types. • Familiarity with NCCI edits, modifier usage, DRG methodology, and common coding denial patterns for inpatient and outpatient service lines. • Proficiency with major EHR and revenue cycle platforms (Epic, Cerner/Oracle Health, Meditech, or equivalent) and denial management workflow tools. • Completion of regulatory/mandatory certifications as required. • Willingness and ability to travel to client or organizational sites as needed.

🏖️ Benefícios

• health insurance • retirement plans • paid time off • flexible work arrangements • professional development