Manager, Centralized Audits and Appeals

UIOWA•Iowa City, IA

7d•Hybrid

About The Position

The Manager, Audits and Appeals provides strategic and operational leadership for the health system's centralized audits and appeals program. The position directs a multidisciplinary team responsible for payer audits, denials management, medical necessity reviews, high-cost outlier forensic audits, government and commercial payer appeals, and audit response operations. The manager applies advanced clinical knowledge, utilization management principles, reimbursement expertise, and regulatory interpretation to mitigate organizational financial risk, optimize reimbursement outcomes, and ensure regulatory compliance. This role serves as the organization's subject matter expert for complex audit and appeal activities and partners with Clinical Documentation Integrity, Utilization Management, Revenue Cycle, Coding, Patient Financial Services, Compliance, and physician leadership to develop proactive denial prevention strategies and strengthen revenue integrity performance. The position is eligible for hybrid work within Iowa. A work arrangement form must be completed upon employment start; arrangements are reviewed annually and must comply with applicable remote work and employee travel policies. The position is not eligible for University employment-authorization sponsorship now or in the future.

Requirements

Bachelor’s degree in business, finance, or a clinical field, or an equivalent combination of education and experience.
Experience with Epic Patient Accounting System.
Five years of experience with professional and facility revenue cycle operations.
Two years of supervisory experience.
Two years of experience with clinical and administrative/technical denials and appeals.
Two years of demonstrated experience conducting complex financial, reimbursement, audit, and denial analyses; ability to quantify net revenue impact, assess regulatory and quality risks, and communicate findings and recommendations to leadership, executive stakeholders, payer relations teams, and external payer representatives.
Working knowledge of claims payment methodologies for physician and hospital reimbursement, such as fee schedules, APR-DRG, EAPG, APC, and per diems.
Understanding of CPT-4 and ICD-10 coding.
Ability to manage multiple large, complex projects simultaneously.
Excellent written and verbal communication skills.
Demonstrated proficiency in Microsoft Office applications.
Advanced experience using Microsoft Excel.
Demonstrated experience working effectively in a welcoming and respectful workplace environment.

Nice To Haves

Master’s degree, preferably in a clinical or administrative field.
Experience with clinical and administrative/technical denials and appeals specific to audits.
Advanced experience performing complex audit, reimbursement, and financial analyses to identify revenue opportunities, assess risk, and quantify net reimbursement impact.
Proven ability to present complex analytical findings and strategic recommendations to leadership and internal and external stakeholders.
Experience with medical coding and/or CPC certification or similar.
Nursing or clinical background.
Familiarity or experience with Epic clinical and/or administrative application build.

Responsibilities

Lead and oversee audit and appeal operations within the centralized audit program, including external payer audits, internal audits, forensic reviews, and release of information.
Establish program metrics, dashboards, reporting cadence, and performance standards for audit and appeal activities in partnership with Revenue Integrity Leadership.
Develop and execute denial and appeal strategies to optimize reimbursement and minimize revenue loss.
Monitor, trend, and report audit and denial KPIs, including overturn rates, audit accuracy, financial impact, and response timeliness.
Translate data into actionable insights and present findings to leadership and stakeholders.
Collaborate with Patient Financial Services, HIM/Coding, Compliance, and clinical teams to resolve audit issues and prevent recurrence.
Ensure compliance with federal regulations, payer requirements, and internal policies.
Establish and refine audit workflows, policies, and controls to strengthen audit readiness and response.
Lead continuous improvement initiatives focused on denial prevention and revenue integrity optimization.
Manage, mentor, and develop audit and appeal staff, including performance management and training.
Serve as the subject matter expert on audit and appeal processes and regulatory changes.
Serve as the primary point of contact for audit tracking software and associated tasks.