Director of Denials and Follow-Up Management

Overview

The Director of Denials and Follow‑up provides strategic oversight, operational management, and financial performance of the organization’s accounts receivable, denial prevention, appeal, and recovery functions. The role partners with Revenue Cycle, Billing, Patient Access, Managed Care, Clinical, Coding, CDI, Utilization Management, and Payer Relations to reduce avoidable denials, optimize appeal success, and improve net‑revenue realization across all payers. As the system‑level leader for follow‑up, denial strategy, collections, analytics, payer escalation, and continuous‑improvement initiatives, the Director ensures alignment with payer contracts, regulatory requirements, and internal clinical and financial priorities.

Key Responsibilities

• Lead strategic oversight and day‑to‑day operations of accounts receivable management, denial prevention, appeal, and recovery efforts.
• Collaborate with cross‑functional teams (Revenue Cycle, Billing, Patient Access, Managed Care, Clinical, Coding, CDI, Utilization Management, Payer Relations) to reduce avoidable denials and improve appeal success rates.
• Develop and execute system‑wide follow‑up and denial‑reduction strategies, including collections, analytics, and payer escalation.
• Ensure compliance with payer contracts, regulatory mandates, and internal clinical/financial policies.
• Monitor industry trends and regulatory changes, assessing impact on Premier Health’s strategic plan and financial performance.
• Coordinate clinical and financial principles across the continuum of care to achieve cost‑effective patient care and optimal resource utilization.
• Manage multiple priorities and projects, adapting quickly to change, driving improvement initiatives, and aligning stakeholders on both clinical and financial fronts.

Required Education

• Master’s degree (required).
• Bachelor’s degree in nursing, business, healthcare administration, or a related field (preferred).

Required Experience

• 7–10 years of progressive experience in healthcare revenue cycle, denials management, managed care, or related functions.
• Demonstrated success leading denial‑reduction and appeal strategies in a complex healthcare environment.
• Strong understanding of payer contracts, authorization requirements, medical‑necessity criteria, and reimbursement methodologies.
• Proven ability to work cross‑functionally with clinical and non‑clinical leaders.

Preferred Qualifications

• Master’s degree such as MHA, MBA, MSN, or similar.
• Experience in a multi‑hospital or integrated health system.
• Clinical background (RN or equivalent) or extensive experience leading clinical and technical denials teams.
• Experience with denial analytics tools and EHR‑based workflows.

Core Skills & Knowledge

• Functional knowledge of revenue‑cycle processes including surprise billing, ABN/HINN letters, LCD/NCD criteria, charging, coding, reimbursement, DRG/APCs, billing, and back‑end collections.
• Ability to analyze industry changes and translate them into actionable strategies.
• Expertise in coordinating clinical and financial principles to ensure compliant payment for care.
• Strong project‑management and diplomatic skills for managing multiple stakeholders.