Denial Prevention Lead

The Denial Prevention Lead (DPL) will oversee a team of Denial Prevention Specialists (DPS) and partner closely with the Revenue Cycle Leadership team to optimize and streamline the denial management process at CND. This role is responsible for guiding the team in the identification, analysis, and resolution of denied claims to support timely reimbursement and enhance overall revenue cycle performance. The DPL will proactively identify and address coding discrepancies and ensure compliance with regulatory standards and internal policies. Utilizing internal systems and tools, the DPL will track, trend, and analyze the root cause of denials, implementing corrective and preventative strategies to minimize future occurrences. The DPL will review the outcomes of appeals and communicate findings and prevention strategies across the organization, including delivering monthly reports summarizing activities by payer and highlighting necessary changes. Additionally, this role will work cross-functionally with other departments to drive improvements through training, coding updates, and process changes.

Job Responsibilities:

• Develop and implement proactive strategies to prevent claim denials at the source, with emphasis on referral accuracy, pre-authorization, eligibility verification , and proper coding.
• Oversee and audit medical coding for accuracy and compliance with ICD-10-CM, AHA Coding Clinic, AMA CPT, and Lifepoint Health Support Center (HSC) guidelines.
• Analyze payer denials across all stages of the revenue cycle to identify root causes and areas for process improvement.
• Draft clear, effective appeals based on detailed medical record reviews and aligned with Medicare, Medicaid, commercial payer, and CND guidelines to ensure timely reimbursement.
• Submit retro-authorization requests as required in response to authorization-related denials, ensuring compliance with payer-specific requirements.
• Conduct routine audits of coding practices, address discrepancies and implement corrective action plans when necessary.
• Collaborate cross-functionally with Billing, Clinical Services, Market Access, and Patient Access teams to optimize denial prevention and improve overall revenue cycle performance.
• Monitor and identify denial trends in claim denials and deliver staff education on best practices to reduce future occurrences.
• Manage denial-related accounts receivable (AR), ensuring timely follow-up and resolution of outstanding claims.
• Process and track correspondence and medical record requests in accordance with department protocols to support efficient and complaint workflows.
• Submit retro-authorization requests in compliance with payer-specific requirements to address and resolve authorization-related denials.
• Complete special projects and initiatives as assigned by leadership.
• Maintain strict adherence to national coding standards (e.g., ICD-10-CM), ethical coding practices (e.g., AHIMA), and internal policies and procedures.

Knowledge, Skills & Experience:

• Minimum of 5 years of experience in medical billing and denial management, including at least 3 years in a supervisory or leadership role, preferably within a diagnostic laboratory setting.
• Comprehensive knowledge of insurance carriers including, HMOs, PPOs, Medicare, Medicaid and other third-party payers.
• Proficiency with platforms such as Salesforce, Waystar, TriZetto, and Quadax is highly desirable
• Strong understanding of ICD-10, CPT, HCPCS coding systems as well as medical terminology.
• Solid knowledge of healthcare regulations, including HIPAA, CMS, and OIG guidelines.
• Familiarity with billing workflows, accounting principles, medical billing practices and electronic health record (EHR) systems.
• Highly detail-oriented with strong time management, organizational and multitasking skills.
• Skilled in interpreting explanation of benefits (EOBs) and remittance advice, with a clear understanding of denial and remark codes.
• Strong analytical and problem-solving skills, with the ability to identify trends and root causes.
• Excellent communication and interpersonal skills to collaborate across departments and external partners.
• Proficient in Microsoft Office, especially Excel and Word.

Education, Certifications & Licensures

• A diploma, certificate, or degree in medical billing and coding, healthcare administration, business, finance, or a related field is required.
• Certification as a Certified Coding Specialist (CCS), Certified Professional Coder (CPC), or equivalent is preferred.

Other:

• This position is a fully remote position. It may require travel for quarterly meetings in our Scottsdale, AZ headquarters or regional office in Atlanta, GA.