Manager, Denials Operations

🕒 il y a 6 jours

🇺🇸 États-Unis – Télétravail

⏰ Temps Plein

🟡 Intermédiaire

🟠 Senior

⚙️ Opérations

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Healthrise

Site WebLinkedInTous les Emplois

51 - 200 employés

⚕️ Assurance santé

☁️ SaaS

Healthcare Insurance • Consulting • SaaS

Healthrise est une entreprise dédiée à fournir des solutions complètes de soins de santé, axées sur la gestion du cycle de revenus, les services de dossiers de santé électroniques (EHR) et le conseil stratégique. Avec plus d'une décennie d'expérience, Healthrise aide les systèmes de santé à travers le pays à atteindre le succès opérationnel et financier grâce à des stratégies sur mesure. Leur équipe d'experts collabore avec des organisations de santé pour relever des défis opérationnels complexes et améliorer l'efficacité, garantissant ainsi que les résultats pour les patients et les finances sont optimisés.

Description

• 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.

🎯 Exigences

• 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.

🏖️ Avantages

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