Job Description
The Sr. Director, Denials Management provides enterprise-level strategic and operational leadership over the organization’s denial management and post-payment audit defense programs. This is a newly created leadership role designed to unify clinical, coding, and technical denial functions under a single accountable leader. This individual will drive towards measurable improvement in overturn rates, write-off reduction, and audit recoupment defense across all facilities and service lines.
This leader 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. They partner directly with the VP of Revenue Cycle, CFO, CMO, and CNO to translate denial data into enterprise-wide corrective action and sustainable revenue protection.
For the right leader, this role offers significant organizational visibility, the opportunity to build and mature a high-performing team, and a direct line to measurable financial impact across the health system.
Duties and Responsibilities
Strategic Leadership & Program Ownership
• Knows, understands, incorporates, and demonstrates the Healthrise Core Values in all interactions with team members, clients, and stakeholders.
• Own the end-to-end strategy for clinical, coding, and technical denial management and post-pay audit defense across all facilities and service lines.
• Establish annual goals for denial overturn rate, appeal yield, write-off reduction, and audit recoupment defense; report performance to executive leadership monthly.
• Partner with the VP of Revenue Cycle, CFO, CMO, and CNO to translate denial trends into enterprise-wide corrective action.
• Build and execute the multi-year roadmap for technology, staffing, vendor partnerships, and process design across the denial and audit portfolio.
Clinical Denials & Appeals
• Direct the clinical appeals team (RN appeal writers, physician advisors, and MD reviewers) handling medical necessity, level-of-care, length-of-stay, and DRG clinical validation denials.
• Oversee preparation of evidence-based appeal letters citing InterQual, MCG, CMS NCD/LCD, and payer medical policy.
• Partner with Utilization Review and Case Management to address front-end documentation gaps driving inpatient and observation denials.
• Manage the physician advisor program and peer-to-peer review workflow for concurrent and retrospective denials.
Coding Denials & DRG Validation
• Lead the coding denial team responsible for DRG downgrades, HCC validation, MS-DRG/APR-DRG disputes, modifier denials, and code-edit rejections.
• Partner with HIM, CDI, and coding leadership to remediate root causes and refine query practices.
• Ensure compliant rebuttal of coding-related findings from commercial payers, Medicare Advantage, RAC, MAC, and SIU audits.
• Maintain a coding appeal playbook aligned with AHA Coding Clinic, ICD-10-CM/PCS Official Guidelines, CPT Assistant, and payer-specific reimbursement policy.
Technical Denials
• Oversee resolution of timely filing, authorization, eligibility, coordination of benefits, medical records request, and credentialing-related denials.
• Drive root-cause analysis back to Patient Access, Scheduling, Utilization Management, Provider Enrollment, and HIM release-of-information.
• Track denial trends by payer, plan, facility, service line, and denial code; produce monthly executive dashboards and corrective action plans.
• Lead negotiations with payers on systemic denial patterns and escalate to managed care contracting when contract language is at issue.
Post-Pay Audits & Recoupment Defense
• Direct the response to all post-payment audits: RAC, MAC, UPIC, SMRC, CERT, OIG, Medicare Advantage payment integrity, commercial payer SIU, and itemized bill reviews.
• Manage ADR (Additional Documentation Request) workflows, audit logs, and discussion-period and redetermination submissions within CMS deadlines.
• Oversee multi-level Medicare appeals (Redetermination, Reconsideration, ALJ, Medicare Appeals Council) and commercial payer external review processes.
• Maintain the enterprise audit tracker, reserve methodology for contested recoupments, and reporting to Finance and Compliance on exposure.
• Partner with Legal and Compliance on audit findings that surface potential overpayment self-disclosure or False Claims Act exposure.
People Leadership
• Lead a team of 40+ FTEs including Directors, Managers, Supervisors, RN appeal writers, certified coders (CCS, CPC, CIC), and audit analysts.
• Build career ladders, productivity standards, and quality assurance programs for each function.
• Manage vendor partners (appeal services, audit defense firms, outside counsel) including SOW, SLA, and performance governance.
Analytics, Technology & Prevention
• Define data and reporting requirements; partner with Revenue Cycle Analytics to deliver denial root-cause dashboards, prevention scorecards, and ROI on appeal investments.
• Evaluate, implement, and optimize denial management technology (e.g., Epic Resolute, Cerner RevCycle, FinThrive, MDaudit, Change Healthcare, AI-assisted appeal platforms).
• Chair the cross-functional Denials Prevention Committee with representation from Patient Access, UR/CM, HIM/CDI, Coding, PFS, Managed Care, and Compliance.
• Performs other duties as assigned.
Qualifications
Required
• Bachelor’s degree in Nursing, Health Information Management, Healthcare Administration, Business, or related field.
• Minimum 10 years of progressive healthcare revenue cycle experience, with at least 5 years in a senior leadership role over denials, appeals, or audit functions in a hospital, health system, or large physician group.
• Demonstrated track record of measurable improvement in denial overturn rate, write-off reduction, and audit recoupment defense at an enterprise scale.
• Deep working knowledge of CMS regulations (Conditions of Participation, NCD/LCD, IPPS/OPPS, Two-Midnight Rule), commercial payer policy, and the Medicare appeals process through ALJ.
• Expert command of medical necessity criteria (InterQual and/or MCG), ICD-10-CM/PCS, CPT/HCPCS, MS-DRG and APR-DRG methodology, and HCC risk adjustment.
• Experience leading large, multi-site teams (30+ FTEs) including remote staff and vendor partners.
• Proficiency with major EHR/revenue cycle platforms (Epic, Cerner/Oracle Health, Meditech) and denial management tools.
• Completion of regulatory/mandatory certifications as required.
• Willingness and ability to travel to client or organizational sites as needed.
Preferred
• Master’s degree (MHA, MBA, MSN, or MS-HIM).
• Active RN license and/or coding certification (CCS, CPC, CIC, RHIA, RHIT).
• Additional credentials: CHC, CRCR, CHFP, CDIP, or CCDS.
• Experience defending audits at academic medical centers, multi-state health systems, or value-based/risk-bearing organizations.
• Familiarity with payment integrity vendors, AI-assisted denial prevention tools, and analytics platforms (Tableau, Power BI, SQL).
Physical Demands and Work Environment
• Primarily office or remote-based environment with periodic travel (10-20%) to facilities, payer meetings, and industry conferences.
• Prolonged periods of sitting at a desk and working on a computer.
• Ability to communicate clearly in person, by phone, and via video conference.
• Occasional extended hours may be necessary during audit periods or to meet appeal filing deadlines.