Manager, Denial Prevention, Trends and Audits

About the role

The Manager, Denial Prevention, Trends and Audits is a critical Revenue Cycle leadership role responsible for converting denial and audit activity from a reactive, transactional queue into a proactive, analytics-driven program that identifies Hospital Billing (HB) denial trends, diagnoses root cause, and drives targeted, timeline-bound solutions in partnership with every area that touches the HB claim life cycle — Patient Access/Financial Clearance, HB Coding & CDI, Revenue Integrity, Contracting, Case Management/UR, the Epic Optimization Team, and clinical departments. This role owns day-to-day operational performance of the non-clinical HB denial and audit team (technical, administrative, and eligibility/authorization-related denials and audit coordination) and serves as the Revenue Cycle’s primary driver — working in close, ongoing partnership with Brown University Health’s Epic Optimization Team — for maximizing Epic HB system effectiveness: building system-based controls, automation, and standard work that prevent denials before submission, reduce manual rework, and reduce the training burden required to sustain the function. Clinical denial and appeal work (e.g., medical necessity, level-of-care) is managed within Revenue Integrity’s clinical appeal nursing team; this role is directly accountable for partnering with that team so clinical and technical denial strategies operate as one aligned program rather than two disconnected efforts. Strong, hands-on Epic HB expertise is a core and non-negotiable requirement of this role. The manager must be able to read and interpret Epic HB work queue logic, claim edits, and BPA build well enough to translate front-line denial patterns into precise, actionable system change requests for the Epic Optimization Team, and to validate that delivered fixes actually close the gap.

Responsibilities

• Denial Trend Identification & Root-Cause Analytics: Own HB denial trend intelligence; aggregate and analyze Hospital Billing denials by payer, reason/CARC-RARC code, service line, site of care, and root cause; apply structured root-cause analysis (RCA) to identify upstream scheduling, registration, authorization, documentation, coding, or system failures; build and maintain a denial trend dashboard using Epic reporting tools (Cogito, SlicerDicer, Workbench/Radar) to visualize denial rate, volume, dollar impact, and recovery rate; quantify impact to prioritize action by dollars at risk, FTE hours consumed, and recurrence rate.
• Cross-Functional Partnership & Targeted Solution Development: Partner with upstream and downstream stakeholders (Patient Access/Financial Clearance, HB Coding & CDI, Revenue Integrity, Contracting/Payer Strategy, Case Management/UR, the Epic Optimization Team, and clinical departments) to convert denial trend findings into targeted, root-cause-specific action plans; lead corrective action planning, define accountable owners, proposed solutions, and implementation timelines; track progress to closure and validate fixes through post-implementation denial-rate monitoring; facilitate a recurring cross-functional denial governance forum; escalate systemic issues to leadership with supporting data and recommended resolution paths.
• Epic Optimization & Systemic Controls: Serve as the primary Denial Prevention liaison to the Epic Optimization Team, translating recurring HB denial and audit patterns into concrete Epic build requests (work queue logic, claim edits, Best Practice Advisories, medical necessity checks, real-time eligibility and authorization edits, charge/order routing rules); identify prevention-first system opportunities using Epic functionality to intercept root causes before claim submission; partner directly with the Epic Optimization Team on testing, validation, and go-live support for system changes tied to HB denial prevention; monitor post-go-live performance to confirm controls work as intended and quantify impact; build systemic and process controls (standard work, templates, system edit checks) that reduce reliance on manual review and rework and lower training volume.
• Quantifiable Impact & Continuous Improvement: Establish and report against improvement targets (reduction in denial volume attributable to systemic/process fixes, reduction in manual touches per account, reduction in average new-hire training time driven by system automation and standard work, improvement in first-pass resolution rate, reduction in preventable denial write-offs); maintain a solution tracker documenting each denial trend identified, its root cause, corrective action taken, accountable owner, timeline, and quantified outcome for leadership reporting.
• Daily Operations & Work Queue Management: Oversee daily HB denial and audit work queues, ensuring proper distribution, prioritization, and timely follow-up; monitor staff productivity, account volumes, and aging to ensure adherence to established SLAs; ensure high-dollar and aging accounts are identified, prioritized, and escalated appropriately; conduct routine audits of staff work to validate accuracy of account review, documentation, and resolution actions; maintain clear guidelines for when accounts can be adjusted, escalated, or require additional review.
• Denial Resolution Execution (Technical & Medical Necessity): Manage the end-to-end technical/medical necessity HB denial and reconsideration process (eligibility, authorization, timely filing, coding/billing edits, coordination of benefits), ensuring timely submission and follow-up; ensure staff accurately review denial codes and payer correspondence, submit complete and compliant non-clinical appeal packages, and document all actions within the system; partner closely with Revenue Integrity’s clinical appeal nursing team to ensure seamless hand-off of clinically driven denials and shared visibility into combined denial trend data; track and report on daily and weekly denial volumes, resolution rates, and backlog status; enforce accountability for timely filing deadlines and appeal turnaround times.
• Audit Intake & Response Coordination: Oversee intake of all HB audit requests and ensure timely assignment and tracking; coordinate required documentation (medical records, coding validation, billing support) across departments; ensure all audit responses are submitted within payer/regulatory deadlines, and are complete, accurate, and properly documented; maintain a centralized audit tracker with status, due dates, and outcomes.
• Quality Assurance & Documentation Standards: Implement and monitor standard work for account review and documentation; perform routine QA reviews to ensure appropriate denial categorization, complete account notes supporting decisions, and compliance with internal policies and audit requirements; provide real-time feedback and coaching to staff to improve quality and consistency.
• Performance Management & Staff Oversight: Directly manage a team of non-clinical denial/audit specialists and analysts, including daily productivity