Associate Director, Billing Strategy – Denials & Appeals

📋 Description

• Oversee the strategy for denial management and appeals across all types of payers.

• Establish and monitor overturn rates, timelines for appeals, and recovery metrics.

• Serve as an internal authority on payer policies and medical necessity criteria related to laboratory testing.

• Analyze payer policies and guide teams in defending medical necessity during appeals.

• Recognize payer behavior patterns to inform strategies for contracting and escalation pathways.

• Collaborate with eligibility, prior authorization, coding, and billing teams to proactively minimize denials.

• Evaluate BPO/vendor performance through data analysis to pinpoint workflow gaps, ensure accountability, and drive enhancements.

• Create job aids and standardized workflows to enhance consistency and quality.

• Examine denial trends to differentiate between avoidable operational issues and systemic or payer-driven challenges.

• Convert denial and appeals workflows into system logic while partnering with engineering and vendors to facilitate automation development.

• Determine requirements for rules-based workflows, denial routing, and appeal triggers in billing systems (e.g., AMD).

• Contribute to automation projects (e.g., rules engines, RPA, AI-driven workflows) by offering domain expertise and guiding design decisions.

• Direct user acceptance testing (UAT) and quality assurance (QA) for system changes, ensuring outputs align with payer policies and actual denial scenarios.

• Discover opportunities to decrease manual tasks by transitioning denial and appeal processes towards scalable, low-touch, or unattended workflows.

• Proactively pinpoint edge cases, failure points, and gaps in automation logic before and after deployment.

• Utilize tools such as Power BI, SQL, Excel, or Snowflake to analyze datasets and quantify denial drivers and their financial implications.

⛳️ Requirements

• 8–12+ years of experience in healthcare Revenue Cycle Management (RCM), with a strong emphasis on denials and appeals.

• Proficiency in laboratory billing, CPT coding, and reimbursement methodologies is highly preferred.

• In-depth knowledge of commercial, Medicare, Medicaid, and managed care payer policies.

• Proven track record of enhancing appeal overturn rates and addressing medical necessity denials.

• Experience collaborating with BPO or offshore RCM vendors.

• Strong analytical capabilities with experience using tools like Power BI, Excel, SQL, or Snowflake.

• Experience leading initiatives across functions and influencing stakeholders without direct authority.

🏝️ Benefits

• Comprehensive medical, dental, vision, life, and disability plans for eligible employees and their dependents.

• Free testing for Natera employees and their immediate families.

• Fertility care benefits.

• Pregnancy and baby bonding leave.

• 401k benefits.

• Commuter benefits.

• Generous employee referral program.