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.