Healthrise

Operations

• 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.

Manager, Denials Operations

Director

• Provides enterprise-level strategic and operational leadership over the organization’s denial management and post-payment audit defense programs.
• Drives towards measurable improvement in overturn rates, write-off reduction, and audit recoupment defense across all facilities and service lines.
• Owns the end-to-end denial lifecycle: prevention strategy, appeal operations, payer relations, post-pay audit response, and the technology and analytics infrastructure supporting the program.
• Partners directly with the VP of Revenue Cycle, CFO, CMO, and CNO to translate denial data into enterprise-wide corrective action and sustainable revenue protection.
• Establish annual goals for denial overturn rate, appeal yield, write-off reduction, and audit recoupment defense; report performance to executive leadership monthly.
• Directs the clinical appeals team handling medical necessity, level-of-care, length-of-stay, and DRG clinical validation denials.
• Oversees preparation of evidence-based appeal letters citing InterQual, MCG, CMS NCD/LCD, and payer medical policy.
• Manages the physician advisor program and peer-to-peer review workflow for concurrent and retrospective denials.
• Leads the coding denial team responsible for DRG downgrades, HCC validation, MS-DRG/APR-DRG disputes, modifier denials, and code-edit rejections.
• Ensures compliant rebuttal of coding-related findings from commercial payers, Medicare Advantage, RAC, MAC, and SIU audits.
• Directs the response to all post-payment audits and manages ADR workflows, audit logs, and other responses within CMS deadlines.
• Builds career ladders, productivity standards, and quality assurance programs for each function.

Senior Director, Denials Management

• Provide strategic and operational leadership across reimbursement integrity, payment validation, revenue optimization, and payer oversight activities across the health system.
• Drive initiatives focused on financial accuracy, reimbursement integrity, operational improvement, and regulatory compliance across the revenue cycle continuum.
• Partner with Revenue Cycle, Compliance, Finance, HIM, Managed Care, and Clinical Operations leadership to identify reimbursement trends and improve operational workflows.
• Oversee complex payer review activity, reimbursement escalations, external validation requests, and governmental and commercial payer inquiries.
• Develop and manage reimbursement resolution strategies including appeals coordination and payer dispute management.
• Recruit, lead, and develop a team of revenue integrity analysts and reimbursement specialists; set performance goals and ensure staff education and training.
• Ensure all reimbursement integrity and payment review activities comply with CMS regulations, OIG guidance, False Claims Act requirements, and applicable state laws.
• Drive identification and resolution of reimbursement variances and payment discrepancies impacting organizational financial performance.
• Collaborate with Clinical Documentation Improvement (CDI), Case Management, Coding, and Billing teams to address audit findings.

Director, Revenue Integrity Strategy

• Provides specialized operational and strategic leadership over the full scope of the organization's clinical denial management function.
• Responsible for driving clinical appeal performance across medical necessity, level-of-care, length-of-stay, DRG clinical validation, and experimental or non-covered service denials for all payer types and service lines.
• Owns the clinical denial function end to end, from the quality of individual appeal letters to the design of appeal workflows.
• Develops clinical appeal writers and manages cross-functional partnerships that address root causes before denials occur.
• Engages physician advisors, payer medical directors, and executive stakeholders with confidence.
• Builds a high-performing clinical appeals team and shapes the clinical denial strategy for a complex, multi-payer organization.

Director, Clinical Denials

Financial Planning and Analysis

• Serve as the operational leader over PFS functions for assigned Healthrise clients, ensuring day-to-day activities meet or exceed performance standards.
• Directly manage and mentor team leads, supervisors, and staff across multiple functional areas (hospital billing, professional billing, A/R follow-up, denials, customer service, etc.).
• Use data-driven insights to identify pain points and take a proactive, action-oriented approach to resolving them, whether that means coaching a team, implementing a new workflow, or stepping in personally to solve a persistent issue.
• Partner with analytics and client stakeholders to define KPIs and develop performance dashboards.
• Implement best practices across systems and teams, especially in Epic, Cerner, or Meditech environments.
• Lead with a “boots-on-the-ground” mindset, participate in root cause reviews, help draft appeal letters, coach teams on difficult accounts, and develop SOPs from real-time observations.
• Drive employee engagement and foster a strong, accountable team culture through transparent communication, clear expectations, and continuous feedback.

Director of Patient Financial Services

Manager

• Overseeing the Quality Audit (QA) program
• Managing QA system access and maintaining accuracy of the staff roster
• Leading documentation efforts including SOPs and training materials
• Providing leadership to both domestic and global teams
• Monitoring the accuracy and completeness of audit results
• Developing strategies to enhance audit processes, tools, and outcomes
• Overseeing the Atlas QA user access request process
• Ensuring documentation is accurate and reflective of current processes
• Tracking training rollout and compliance
• Communicating with senior leadership and department heads
• Facilitating collaboration across domestic and global teams
• Providing direct leadership to the domestic quality audit team
• Assigning and monitoring workloads
• Conducting regular performance reviews and team meetings
• Developing team members through coaching and mentoring

Manager, Denials Operations

Senior Director, Denials Management

Director, Revenue Integrity Strategy

Director, Clinical Denials

Director of Patient Financial Services

Manager – Quality and Training