Associate Director, Billing Strategy - Denials & Appeals
Accountabilities: Lead the overall denial management and appeals strategy across commercial, Medicare, Medicaid, managed care, and other payer environments, establishing performance expectations and improvement priorities.
Define and monitor key performance indicators including appeal overturn rates, appeal timelines, recovery performance, denial rates, and financial impact.
Serve as a subject matter expert on payer policies, medical necessity criteria, laboratory testing reimbursement, and the requirements needed to build compelling appeals.
Interpret payer policies and guide internal and outsourced teams in developing effective strategies for defending medical necessity and resolving complex denials.
Analyze payer behavior and denial patterns to identify systemic issues, inform payer advocacy efforts, and support contracting and escalation strategies.
Partner with eligibility, prior authorization, coding, billing, and other revenue cycle functions to identify upstream issues and proactively reduce preventable denials.
Oversee and evaluate outsourced RCM and BPO performance, using data to identify workflow gaps, enforce accountability, and drive measurable improvements.
Develop standardized workflows, job aids, and operating practices that improve consistency, quality, efficiency, and results across denial and appeal activities.
Translate denial and appeals processes into system requirements and logic, partnering with engineering teams and vendors to support billing system enhancements and automation.
Define requirements for rules-based workflows, denial routing, appeal triggers, and other capabilities within billing platforms and related systems.
Provide domain expertise for automation initiatives involving rules engines, RPA, AI-enabled workflows, intelligent routing, and decisioning.
Lead user acceptance testing and quality assurance for system changes, validating that automated outputs reflect payer policies and real-world denial scenarios.
Identify manual processes that can be transitioned to scalable, low-touch, or unattended workflows while proactively identifying edge cases, failure points, and gaps in automation logic.
Use analytical tools such as Power BI, SQL, Excel, and Snowflake to quantify denial drivers, identify trends, evaluate financial impact, and support data-driven decision-making.
Influence cross-functional stakeholders across operations, engineering, vendors, and leadership without relying on direct reporting authority.
Requirements
8–12+ years of healthcare Revenue Cycle Management experience, with deep specialization in denials and appeals.
Strong expertise in laboratory billing, CPT coding, reimbursement methodologies, medical necessity, and payer-specific requirements.
Comprehensive knowledge of commercial, Medicare, Medicaid, and managed care payer policies and practices.
Demonstrated success improving appeal overturn rates, resolving medical necessity denials, reducing denial drivers, and improving reimbursement outcomes.
Experience managing or partnering with BPO and offshore RCM vendors, including performance oversight, quality management, and operational improvement.
Strong analytical capabilities with hands-on experience using tools such as Power BI, Excel, SQL, and/or Snowflake to analyze operational and financial data.
Proven ability to lead complex cross-functional initiatives and influence stakeholders across operations, technology, engineering, vendors, and leadership without direct authority.
Experience supporting revenue cycle automation initiatives, such as rules engines, RPA, workflow automation, or similar technologies, is preferred.
Experience partnering with engineering teams or technology vendors to implement billing system enhancements and translate operational processes into system requirements is preferred.
Familiarity with AI-driven operational workflows, including intelligent routing and decisioning, is preferred.
Experience with AMD or similar billing platforms is preferred, along with familiarity with Jira or comparable workflow tracking systems.
Strong investigative and problem-solving abilities, with a persistent approach to understanding why denials occur and how they can be prevented or overturned.
Systems-thinking mindset with the ability to connect operational processes, business requirements, system logic, and automation opportunities.
Data-driven decision-making skills, combined with strong communication, stakeholder management, and influencing capabilities.
Builder mindset, high ownership, strong accountability, and a collaborative approach focused on outcomes and team success.
Benefits
Base salary: $132,100–$165,100 USD for the remote U.S. position.
Compensation may vary based on skills, years and depth of experience, certifications, and specific work location, including applicable cost-of-labor considerations.
Comprehensive medical, dental, and vision insurance for eligible employees and dependents.
Life and disability insurance plans.
Free testing for employees and their immediate families.
Fertility care benefits.
Pregnancy and baby bonding leave.
401(k) benefits.
Commuter benefits.
Employee referral program.
Remote work opportunity across the United States.
Opportunity to work at the intersection of healthcare revenue cycle management, payer strategy, data analytics, and emerging automation technologies.
Cross-functional exposure to operations, engineering, technology vendors, and senior leadership.
Meaningful opportunity to improve reimbursement performance and build scalable, technology-enabled healthcare processes.
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