Manager, Appeals & Denials

Accuity

2d•Remote

About The Position

The Manager, Appeals & Denials oversees the day-to-day inpatient DRG downgrade and appeals process. The role tracks, prioritizes, and trends denials; writes and develops appeal letters; identifies and delivers education; and manages staff, audits, and reporting. The Manager supports high-quality appeals for Accuity clients, strengthens client relationships, and ensures appeals reflect the patient’s clinical picture and comply with ethical coding practices and applicable requirements. The position works with the Appeals & Denials, CDI, Coding, and DRG teams, the Appeals Medical Director, physicians, and client healthcare teams. It applies clinical expertise, clinical documentation improvement practices, coding guidelines, state and federal regulations, and facility-specific tools to support accurate, defensible appeals and program quality.

Requirements

Registered Nurse or degree in Healthcare Management, Healthcare Administration, Health Information Management, or a related field.
At least 5 years of appeals/denials or inpatient coding experience.
At least 5 years of management experience.
Extensive knowledge of revenue cycle management and coding services.
Extensive operational knowledge of physician and hospital revenue cycles.
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 in a healthcare or similar environment.
Ability to interpret coding quality audit data, track and trend results, and translate findings into 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.
Strong interpersonal and customer service skills.
Ability to work effectively in a remote environment as a motivated and self-directed professional.
Strong analytical and problem-solving skills, including gathering and interpreting data, identifying opportunities, and applying sound judgment.
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 meet objectives on time.
Ability to establish and maintain effective working relationships with physicians, staff, clients, and cross-functional partners.
Ability to manage competing priorities while maintaining accuracy, quality, and timely execution.
Ability to interact with people and technology while sitting or standing, communicate by phone and email, and sit for extended periods, with or without reasonable accommodation.

Nice To Haves

CCDS and/or CDIP certification or RHIA/RHIT certification.

Responsibilities

Distribute daily assignments and monitor workload and updates throughout the day.
Review client denials, determine appropriate next steps, and distinguish clinical denials from coding-related denials; review medical records as needed to support appeal arguments.
Track and trend denial data and prioritize denials according to client and Accuity deadlines.
Write and support the development of high-quality appeal letters for Accuity clients.
Review No Appeal letters and determine whether the decision is appropriate or an appeal can be pursued; provide feedback to Appeal Writers.
Help maintain the accuracy and integrity of data in Appeals & Denials tracking software.
Ensure adequate staffing for workload and assist teams when workload exceeds capacity.
Conduct regular quality and compliance audits, identify improvement opportunities, and provide timely constructive feedback.
Supervise, mentor, coach, and develop assigned Appeals and Denials staff.
Conduct annual performance evaluations and address interim performance concerns.
Review and approve employee timecards each pay period.
Manage staffing resources and time-off requests to ensure operational coverage.
Support onboarding, training, and continuing education for new and existing staff.
Analyze appeal letters and audits and recommend education, counseling, or termination of staff as appropriate.
Identify denial and coding trends, develop related education, and deliver it to staff and relevant teams.
Ensure compliance with external agency requirements and applicable state and federal regulations for ethical coding.
Identify and implement improvements to coding quality and client satisfaction.
Document patterns, trends, and variations in coding data and collaborate with other departments to resolve or explain variances.
Monitor changes to external regulations, statutes, and standards, facilitate implementation of revised requirements, and support ongoing compliance.
Interpret coding quality audit data, track and trend results, and translate findings into coding education.
Collaborate with Appeals & Denials, CDI, physician, Coding, DRG, and client healthcare teams to support accurate and defensible appeals.
Establish and maintain cooperative working relationships with physicians, staff, clients, and internal departments.
Support client satisfaction through timely, accurate, high-quality appeals and denial management.
Assist the Director, Denials & Appeals with assigned projects and tasks, and perform other related duties as assigned.