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Summary

The Denial, Appeal, and Audit Manager is responsible for the oversight and management of all payer denials, appeals, and audit processes within the health system. This role ensures timely resolution of claim denials, effective appeal strategies, and proactive audit response. The manager leads a team of specialists, coordinates with internal departments, and liaises with payers to recover appropriate reimbursement and prevent future revenue leakage. The role demands a strong understanding of payer policies, clinical documentation, and regulatory compliance.

Experience

10 years prior experience in healthcare or insurance with responsibility in revenue cycle billing, reimbursement and denial mitigation.

Must possess excellent working knowledge in the area of health care revenue cycle billing, strong medical terminology, reimbursement and insurance regulations required.

Prior experience in EPIC preferred.

Skills Required

+ Strong leadership and staff development capabilities

+ Analytical skills to identify trends and drive performance improvement

+ Excellent verbal and written communication, particularly for appeal letters and audit responses

+ Proficiency in Microsoft Excel, PowerPoint, and analytics/reporting tools

+ Ability to manage multiple priorities in a fast-paced environment

Education

Bachelor’s degree in health administration, Nursing, Business or related field required. This requirement may be satisfied through an equivalent combination of education and 10 years prior experience in healthcare, or insurance with responsibility and management of billing and reimbursement.

Essential Functions

Denials & Appeals Management

+ Oversee daily operations of the denials and appeals team across all service lines (hospital, physician, outpatient, etc.)

+ Analyze denial trends and root causes; develop strategies to reduce preventable denials

+ Ensure appeals are written and submitted timely, with clinical accuracy and regulatory compliance

+ Monitor and ensure adherence to payer-specific appeal timelines and protocols

+ Collaborate with clinical, utilization management, billing, HIM, and coding teams to resolve medical necessity and coding-related denials

Audit Oversight

+ Manage payer and third-party audits (e.g., RAC, MAC, UPIC, commercial payers)

+ Coordinate timely record retrieval, clinical validation, and response submission

+ Track audit outcomes, appeal adverse decisions, and maintain detailed audit logs

+ Mitigate risk by monitoring changes in audit regulations and updating policies accordingly

Reporting & Analytics

+ Create and maintain dashboards and reports to track denial rates, appeal success rates, and audit recoveries

+ Provide monthly summaries to senior leadership, identifying trends and recommending corrective actions

+ Evaluate staff performance through productivity and quality metrics

Leadership & Compliance

+ Recruit, train, and supervise denial and appeal specialists and auditors

+ Ensure team compliance with HIPAA, CMS, and payer requirements

+ Develop and update internal policies and workflows for denial, appeal, and audit functions

+ Serve as a subject matter expert on denial management and audit response best practices

+ Maintains knowledge of and complies with established policies and procedures including government, insurance, and collection regulations.

+ Attends meetings and participates in committees as requested. Conducts special projects and studies as directed.

+ Manages within established budget including annual planning.

+ Coaches, develops, and builds teamwork with employees. Strives for a tier 1 team and makes the workplace productive as well as ensures transparent and open communication exists up and down the employee/peer spectrum. This includes clear demonstration of Guthrie’s Mission & Values.

+ Actively participates as a team member by supporting decisions, accepting change, managing conflict effectively, and valuing the contributions of others.

+ Maintains strict confidentiality related to patient health information in accordance with HIPAA compliance.

+ Participates in professional development efforts to ensure current with health care practices and trends.

+ Serves as a role model and keeps department focused on processes that result in maximum efficiencies and revenue capture.

+ Key Performance Metrics include:

+ Overall Denial Rate

+ Primary Denial Rate

+ Authorization Denial Raate

+ Coding Denial Rate

+ Medical Necessity Denial Rate

Required Knowledge, Skills and Abilities

+ The manager must have a clear understanding of multiple managed care contracts, multiple specialty insurance and billing practices, and exercise professional competency in reviewing accounts to maximize reimbursement and minimize financial risk to The Guthrie Clinic. Successful oversight will result in increased net revenues by reducing bad debt from potential write-offs. Interactions will primarily be conducted with staff, leaders, vendors and results of efforts will drive actions to secure payment for open balances. Serves as a resource to faculty, managers, and clinic staff in all denial related issues.

+ Accountable and responsible for analyzing and reducing denials.

+ Exceptional communication skills, ability to explain, advocate, and express facts and ideas in a convincing manner, and negotiate with individuals and groups internally and externally.

+ Emotional intelligent and tactful in all situations.

+ Superior presentation skills, able to present in a clear and articulate fashion in front of a variety of constituents.

+ Committed to a "team approach" and encourages a collaborate process, working effectively with a diverse or multi-disciplinary group to achieve a common goal.

+ Demonstrated knowledge and understanding of Epic, and Governmental/non-government requirements applicable to insurance billing processes.

+ Demonstrated project management skills including managing multiple projects in a timely and efficient manner. Demonstrated abilities in utilizing Lean/project management protocols for efficient workflows.

+ Demonstrated analytical, problem-solving abilities, strong organization and decision-making abilities with data, people and situations.

+ Demonstrated familiarity, knowledge and understanding of relevant Hospital Policies, Practices and HIPAA regulations.

+ Demonstrated skills and proficiencies of Microsoft Excel, Word, Project or other spreadsheet and/or word processing software.

+ Work independently with strong follow-up skills to ensure effective and efficient completion of tasks.

+ Adapts to change plan/influence strategies to the organization's political realities and constraints.

+ Outstanding relationship management skills, easily builds strong and effective working relationships within a climate of trust, inspires cooperation and confidence and is a true consensus builder

Other Duties

+ Travel for this position is sometimes required.

+ Participation in community and employee engagement activities is required.

+ It is understood that this description is not intended to be all-inclusive and that other duties may be assigned as necessary in the performance of this position.

Upload 9-22-25

Joining the Guthrie team allows you to become a part of a tradition of excellence in health care. In all areas and at all levels of Guthrie, you’ll find staff members who have committed themselves to serving the community.

The Guthrie Clinic is an Equal Opportunity Employer.

The Guthrie Clinic is a non-profit, integrated, practicing physician-led organization in the Twin Tiers of New York and Pennsylvania. Our multi-specialty group practice of more than 500 physicians and 302 advanced practice providers offers 47 specialties through a regional office network providing primary and specialty care in 22 communities. Guthrie Medical Education Programs include General Surgery, Internal Medicine, Emergency Medicine, Family Medicine, Anesthesiology and Orthopedic Surgery Residency, as well as Cardiovascular, Gastroenterology and Pulmonary Critical Care Fellowship programs. Guthrie is also a clinical campus for the Geisinger Commonwealth School of Medicine.