Clinical Appeals & Denials Manager

R1 is the leading provider of technology-driven solutions that transform the patient experience and financial performance of hospitals, health systems and medical groups. We are the one company that combines the deep expertise of a global workforce of revenue cycle professionals with the industry’s most advanced technology platform, encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration.

As our Clinical Appeals and Denials Manager, you will serve as an expert on clinical appeals and denials management. Every day you will support client hospitals where claims were denied or underpaid by governmental contractors, third-party auditors, or other payers. You will oversee the Clinical Appeals staff, strategically manage the appeals inventory and workflow, and continuously refine efficiencies through process improvement. The Manager is responsible for ensuring client satisfaction and department goals are met and maintained. To thrive in this role, you must have prior leadership experience in a high-volume inventory management setting that includes medical record reviews or clinical denial management.

Responsible for the oversight of department supervisor(s) and overall department vision. Mentors, supports, and coaches the team, providing feedback and education as needed. Ensures and helps establish alignment with division cash goals, adjusting account focus as needed. Coordinates efforts across all operational & support verticals to ensure optimization of workflow Review and analyze denial reports, identify trends and root causes, and implement corrective actions to prevent future denials. Manage the appeals process, ensure compliance with payer policies and regulations, and negotiate with insurance companies to resolve disputed claims. Collaborate with other departments, such as coding, clinical documentation, and patient access, to improve the quality and accuracy of billing and documentation. Develop and maintain policies and procedures for denials and appeals management, ensure adherence to best practices and industry standards, and update them as needed. Prepare and present monthly reports on denials and appeals metrics, such as denial rate, appeal success rate, aging AR, and revenue recovery. Identify opportunities for process improvement, cost reduction, and revenue enhancement, and implement solutions to optimize the revenue cycle.