Coding & Clinical Denials Sr. Associate Team Lead - US Territory

Qualifications:

-4-8 years of experience in healthcare revenue cycle management, with a specific focus on coding and clinical denials, accounts receivable, and team leadership.

-Deep understanding of medical coding (ICD-10, CPT, HCPCS) and clinical denials, payer medical necessity policies, and clinical documentation improvement principles.

-Proven expertise in denial management lifecycle — identification, analysis, appeal management, and prevention of coding and clinical denials.

-Strong knowledge of medical billing processes, insurance claims, clinical documentation requirements, and overall revenue cycle operations.

-Experience interacting effectively with internal stakeholders (coding, clinical teams, and billing), insurance payers, and external audit teams.

-Mandatory Epic system experience.

-Willing to work on a night shift schedule

Responsibilities:

Team Management and Leadership:

-Supervise and mentor a team specializing in coding and clinical denials, providing coaching to enhance knowledge on denial reasons, documentation gaps, and appeals processes.

-Conduct regular team meetings, one-on-one coaching sessions, and performance reviews to drive accountability and continuous improvement.

-Foster a collaborative, results-driven environment focused on reducing denial rates and improving recovery outcomes.

Denials Management Oversight:

-Oversee the denial management process focusing on coding and clinical denials to optimize cash flow and reduce write-offs.

-Monitor denial trends, payer behavior, and root causes related to coding and clinical documentation.

-Collaborate with clinical teams, coders, and billing teams to ensure accurate coding and documentation compliance to prevent denials.

-Lead efforts in reviewing denied claims, determining medical necessity issues, preparing appeal documentation, and tracking resolution success.

Insurance and Payer Relations:

-Manage escalated claim denials involving complex coding and clinical documentation issues.

-Build and maintain strategic relationships with payer representatives to facilitate timely resolution of denials.

-Keep abreast of payer policy updates, changes in medical necessity criteria, and regulatory shifts impacting coding/clinical denial submissions and appeals.

Process Improvement and Training:

-Identify gaps in internal denial workflows and develop initiatives to streamline processes and reduce denial volume.

-Create and deliver focused training programs on coding guidelines, clinical documentation improvement (CDI), and payer medical necessity standards for internal teams.

-Implement and maintain denial prevention best practices and continuous education to enhance team effectiveness.

Reporting and Analytics:

-Generate and analyze regular reports on denial trends, denial rates (especially coding and clinical denials), appeals outcomes, and financial impact.

-Use data insights to recommend corrective actions and guide strategic decisions to improve denial management outcomes.

-Track key performance metrics such as denial resolution turnaround time, appeal success rate, and denial write-off dollar reduction.

Preferred PMS Experience:

-Mandatory Epic HB (Hospital Billing) and Epic PB (Professional Billing) system experience.