Job purpose

The Appeals Lead provides advanced oversight of insurance denial and underpayment management, serving as both a senior technical expert and operational leader within Revenue Cycle Management. This role is responsible for managing complex appeals, monitoring denial and appeal performance trends, training and mentoring Appeals Specialists, and ensuring consistent execution of best practices. The Appeals Lead plays a critical role in driving improved reimbursement outcomes, reducing preventable denials, and promoting accountability through KPI monitoring and staff development.

Duties and responsibilities

Appeals and Denial Management

• Reviews unpaid, underpaid, and denied claims to determine appeal      viability, with a focus on high-dollar, high-risk, and complex cases.
• Prepares, reviews, and submits written appeals, grievances, and      reconsideration requests with complete and accurate supporting      documentation.
• Provides quality review and guidance on appeal letters prepared by      Appeals Specialists to ensure accuracy, compliance, and effectiveness.
• Researches payer contracts, policies, medical necessity criteria,      and regulatory guidelines to support appeal arguments.
• Interprets ERAs, EOBs, zero-pay remittances, and payer      correspondence to ensure correct reimbursement.
• Ensures all appeals are submitted within payer-specific,      contractual, and regulatory timelines.

Denial Trend Analysis and KPI Oversight

• Oversees denial and appeal tracking processes to ensure accurate      and consistent data capture.
• Monitors and analyzes denial trends by payer, denial reason,      procedure, provider, and department.
• Tracks and reports key performance indicators (KPIs), including but      not limited to: 
  • DAR; Days in AR
  • Percent paid by 91st day
  • Period Buckets
  • Team and individual productivity
  • Appeal success and overturn rates
  • Dollars recovered
  • Aging of appealed claims
  • Denial volume and repeat denial patterns
• Prepares and presents detailed denial and appeal performance      reports for leadership.
• Identifies root causes of denials and recommends process      improvements to reduce future occurrences.
• Partners with leadership to establish performance expectations and      benchmarks for the appeals team.

Training, Mentorship, and Team Support

• Trains new Appeals Specialists on appeal workflows, payer      requirements, denial types, documentation standards, and best practices.
• Provides ongoing coaching, mentoring, and performance feedback to      Appeals Specialists.
• Develops and maintains training materials, workflows, and reference      tools related to appeals and denial management.
• Monitors individual and team performance against KPIs and supports      corrective action or additional training as needed.
• Serves as a subject-matter expert and escalation point for complex      appeal and denial issues.

Leadership and Cross-Functional Collaboration

• Collaborates with billing, coding, clinical, utilization review,      and front-office teams to resolve systemic denial issues.
• Provides actionable feedback to improve documentation, coding      accuracy, and front-end claim submission practices.
• Participates in audits, payer reviews, and special revenue      optimization projects.
• Demonstrates accountability for appeal outcomes and continuous      process improvement initiatives.

Billing and Accounts Receivable Support

• Manages assigned and make assignments for Accounts Receivable      worklists and follow-up activities as needed.
• Assists with posting insurance and patient payments accurately and      timely.
• Submits corrected claims and documentation in electronic or paper      format as required.
• Contacts insurance carriers regarding claim status, payment      discrepancies, appeal decisions, and refunds.

Patient and Customer Service

• Assists with complex patient billing inquiries and escalated      issues.
• Coordinates medical and billing documentation with patients and      third-party payers.
• Ensures professionalism, accuracy, and empathy in all patient      communications.

Compliance and Professional Standards

• Maintains strict confidentiality of patient, provider, and company      information in accordance with HIPAA and organizational policies.
• Ensures appeals and documentation comply with federal, state,      payer, and contractual requirements.
• Maintains regular and predictable attendance.

Previous coding experience preferred, not required.

Working conditions

Environmental Conditions: Medical Office environment

Physical Conditions: 

· Must be able to work as scheduled – typically from 8:00 – 5:00 M-F

· Hybrid located at HQ Office 

· Must be able to sit and/or stand for prolonged periods of time

· Must be able to bend, stoop and stretch

· Must be able to lift and move boxes and other items weighing up to 30 pounds.

· Requires eye-hand coordination and manual dexterity sufficient to operate office equipment, etc.