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Guthrie · 15 hours ago

Manager, Denial, Appeal, & Audit

Sayre, PA

Full-time

Onsite

Senior Level, Lead/Staff

10+ years exp

Guthrie is a healthcare organization seeking a Denial, Appeal, and Audit Manager responsible for overseeing all payer denials, appeals, and audit processes within the health system. The role involves leading a team to ensure timely resolution of claims and proactive audit responses while maintaining compliance with payer policies and regulations.

Health CareHospitalPersonal Health

Growth Opportunities

Responsibilities

Oversee daily operations of the denials and appeals team across all service lines (hospital, physician, outpatient, etc.)

Analyze denial trends and root causes; develop strategies to reduce preventable denials

Ensure appeals are written and submitted timely, with clinical accuracy and regulatory compliance

Monitor and ensure adherence to payer-specific appeal timelines and protocols

Collaborate with clinical, utilization management, billing, HIM, and coding teams to resolve medical necessity and coding-related denials

Manage payer and third-party audits (e.g., RAC, MAC, UPIC, commercial payers)

Coordinate timely record retrieval, clinical validation, and response submission

Track audit outcomes, appeal adverse decisions, and maintain detailed audit logs

Mitigate risk by monitoring changes in audit regulations and updating policies accordingly

Create and maintain dashboards and reports to track denial rates, appeal success rates, and audit recoveries

Provide monthly summaries to senior leadership, identifying trends and recommending corrective actions

Evaluate staff performance through productivity and quality metrics

Recruit, train, and supervise denial and appeal specialists and auditors

Ensure team compliance with HIPAA, CMS, and payer requirements

Develop and update internal policies and workflows for denial, appeal, and audit functions

Serve as a subject matter expert on denial management and audit response best practices

Maintains knowledge of and complies with established policies and procedures including government, insurance, and collection regulations

Attends meetings and participates in committees as requested. Conducts special projects and studies as directed

Manages within established budget including annual planning

Coaches, develops, and builds teamwork with employees. Strives for a tier 1 team and makes the workplace productive as well as ensures transparent and open communication exists up and down the employee/peer spectrum. This includes clear demonstration of Guthrie’s Mission & Values

Actively participates as a team member by supporting decisions, accepting change, managing conflict effectively, and valuing the contributions of others

Maintains strict confidentiality related to patient health information in accordance with HIPAA compliance

Participates in professional development efforts to ensure current with health care practices and trends

Serves as a role model and keeps department focused on processes that result in maximum efficiencies and revenue capture

Qualification

Healthcare revenue cycle billingDenial mitigationPayer policies knowledgeEPIC proficiencyLeadership capabilitiesAnalytical skillsMicrosoft Excel proficiencyCommunication skillsProject management skillsTeam collaborationEmotional intelligenceProblem-solving abilities

Required

10 years prior experience in healthcare or insurance with responsibility in revenue cycle billing, reimbursement and denial mitigation

Must possess excellent working knowledge in the area of health care revenue cycle billing, strong medical terminology, reimbursement and insurance regulations required

Strong leadership and staff development capabilities

Analytical skills to identify trends and drive performance improvement

Excellent verbal and written communication, particularly for appeal letters and audit responses

Proficiency in Microsoft Excel, PowerPoint, and analytics/reporting tools

Ability to manage multiple priorities in a fast-paced environment

Bachelor's degree in health administration, Nursing, Business or related field required. This requirement may be satisfied through an equivalent combination of education and 10 years prior experience in healthcare, or insurance with responsibility and management of billing and reimbursement

The manager must have a clear understanding of multiple managed care contracts, multiple specialty insurance and billing practices, and exercise professional competency in reviewing accounts to maximize reimbursement and minimize financial risk to The Guthrie Clinic

Accountable and responsible for analyzing and reducing denials

Exceptional communication skills, ability to explain, advocate, and express facts and ideas in a convincing manner, and negotiate with individuals and groups internally and externally

Emotional intelligent and tactful in all situations

Superior presentation skills, able to present in a clear and articulate fashion in front of a variety of constituents

Committed to a 'team approach' and encourages a collaborate process, working effectively with a diverse or multi-disciplinary group to achieve a common goal

Demonstrated knowledge and understanding of Epic, and Governmental/non-government requirements applicable to insurance billing processes

Demonstrated project management skills including managing multiple projects in a timely and efficient manner

Demonstrated abilities in utilizing Lean/project management protocols for efficient workflows

Demonstrated analytical, problem-solving abilities, strong organization and decision-making abilities with data, people and situations

Demonstrated familiarity, knowledge and understanding of relevant Hospital Policies, Practices and HIPAA regulations

Demonstrated skills and proficiencies of Microsoft Excel, Word, Project or other spreadsheet and/or word processing software

Work independently with strong follow-up skills to ensure effective and efficient completion of tasks

Adapts to change plan/influence strategies to the organization's political realities and constraints

Outstanding relationship management skills, easily builds strong and effective working relationships within a climate of trust, inspires cooperation and confidence and is a true consensus builder