Manager, Appeals & Denials

Manager, Appeals & Denials

Department: Appeals & Denials
Location: Remote
People Leader: Yes
FLSA Status: Exempt
Travel: Less than 5%

Summary

Company Summary

Accuity partners with hospitals and health systems through a technology-enabled, physician-led model that improves clinical documentation integrity, coding accuracy, reimbursement optimization, and quality outcomes.

Job Summary

The Manager, Appeals & Denials is responsible for the day-to-day management and oversight of the inpatient DRG Downgrades and appeals process. This includes tracking, prioritizing, and trending denials; writing appeal letters; identifying training and educational opportunities; and delivering education to CDI Appeals Specialists, Coders, and DRG Reviewers. The Manager supports the Appeals & Denials program through staff oversight, auditing and reporting, mentoring, and strengthening client relationships by ensuring the delivery of high-quality appeal letters for Accuity clients.

This position collaborates with the Appeals & Denials Team, CDI Team, Appeals Medical Director, Coding Team, DRG Team, and client healthcare team members to develop appeal letters that support accurate, comprehensive documentation reflecting the true clinical picture of the patient. The Manager utilizes clinical expertise, clinical documentation improvement practices, current coding guidelines, state and federal regulations for ethical coding, and facility-specific tools to support best practices and compliance with Accuity’s mission and philosophy.

Responsibilities

Appeals & Denials Operations

• Distributes the daily assignments to the department and monitors for any updates or necessary adjustments throughout the day.
• Reviews denials received from clients and applies appropriate knowledge and judgment in determining next steps.
• Determines whether denials are clinical or coding related and reviews the medical record as necessary to appropriately support appeal arguments.
• Tracks and trends denial data and prioritizes denials based on client and Accuity due dates.
• Writes and supports the development of quality appeal letters for Accuity clients.
• Reviews No Appeal letters to determine whether the decision is appropriate or whether an appeal can be pursued and provides feedback to Appeal Writers.
• Assists with maintaining the integrity of data entered into Appeals & Denials tracking software.
• Ensures adequate staffing to support workload and assists teams when workload exceeds available team capacity.
• Conducts regular audits to ensure quality and compliance, identifies opportunities for improvement and provides timely, constructive feedback to support team member development and performance.

Leadership and People Management

• Provides direct supervision, mentoring, coaching, and development to assigned Appeals and Denials staff.
• Conduct annual performance evaluations and address interim performance concerns when necessary.
• Review and approve employee timecards each pay period.
• Manage staffing resources, including time-off requests, to ensure adequate operational coverage.
• Supports onboarding, training, and continuing education initiatives for new and existing staff.
• Assists with audits and analyzes appeal letters, making recommendations for education, counseling, or termination of staff as appropriate.
• Identifies training and educational opportunities, develops, and delivers education based on identified denial and coding trends.

Compliance and Quality

• Ensures compliance with external agency requirements and applicable state and federal regulations for ethical coding.
• Identifies and implements improvement measures designed to enhance coding quality and client satisfaction.
• Identifies and documents patterns, trends, and variations in coding data and collaborates with other departments to resolve or explain identified variances.
• Monitors the initiation, revision, and implementation of external regulations, statutes, and standards; facilitates implementation of revised requirements; and supports ongoing compliance.
• Interprets coding quality audit data, tracks and trends results, and converts findings into applicable coding education.

Cross-Functional Collaboration

• Collaborates with the Appeals & Denials Team, CDI Team, Physicians, Coding Team, DRG Team, and client healthcare team members to support accurate and defensible appeals.
• Establishes and maintains cooperative working relationships with physicians, staff, clients, and internal departments.
• Supports client satisfaction through timely, accurate, and high-quality appeals and denial management.

Other Duties as Assigned

• Assists the Director, Denials & Appeals with projects or tasks as assigned.
• Performs miscellaneous job-related duties as assigned.

Qualifications

Education and Credentials

• Registered Nurse or degree in Healthcare Management, Healthcare Administration, Health Information Management, or another related field required.
• CCDS and/or CDIP certification or RHIA/RHIT certification preferred.

Experience

• Minimum of 5 years of appeals/denials or coding experience in the inpatient coding arena.
• Minimum of 5 years of management experience.
• Extensive knowledge of revenue cycle management and coding services.
• Extensive operational knowledge of both physician and hospital revenue cycle.
• Demonstrated knowledge of ICD-10-CM, ICD-10-PCS, CPT, HCPCS, and modifiers.
• Experience with electronic health records and health information systems.
• Working knowledge of functional relationships between departments within a healthcare or similar environment.
• Demonstrated ability to interpret coding quality audit data, track and trend results, and translate findings into applicable coding education.
• Experience overseeing denials and appeals operations, including scheduling, work distribution, productivity monitoring, and quality output.
• Proficiency using a PC in a Windows environment, including Microsoft Word.

Core Competencies

• Strong interpersonal and customer service skills.
• Highly motivated and self-directed, with the ability to work effectively in a remote environment.
• Strong analytical and problem-solving skills, with the ability to gather and interpret data, identify areas of opportunity, and apply sound judgment.
• Demonstrated leadership skills, including accountability, decision-making, coaching, and counseling.
• Highly developed written and verbal communication skills.
• Strong organizational and prioritization skills, with the ability to ensure objectives are met in a timely manner.
• Ability to establish and maintain effective, cooperative working relationships with physicians, staff, clients, and cross-functional partners.
• Ability to manage competing priorities while maintaining accuracy, quality, and timely execution.

Additional Requirements

1) Physical Requirements: The requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job with or without reasonable accommodations. Unless otherwise indicated, Accuity positions require interaction with people and technology while either sitting or standing. Employees must be able to communicate via phone, email, etc. and sit for extended periods of time, with or without reasonable accommodations. Physical effort and exposure to physical risk are limited to that of an office role / environment.

2) Position and Employment Statement: While this job description is intended to be an accurate reflection of the job requirements, management reserves the right to modify, add or remove duties from a job and to assign other duties as necessary and at any time. All positions at Accuity Delivery Systems, LLC, are at-will employment, and a position description is not a guarantee of a job or of job responsibilities.

While this job description is intended to be an accurate reflection of the job requirements, management reserves the right to modify, add or remove duties from a job and to assign other duties as necessary and at any time. All positions at Accuity are at-will employment, and a position description is not a guarantee of a job or of job responsibilities.