Position Summary:
The RCM Denials & Payor Compliance Specialist is responsible for resolving upheld and complex billing denials, strengthening internal billing processes, and ensuring alignment with payor guidelines. This role serves as a key partner to the RCM Director in improving collections performance, reducing denial trends, and maintaining compliance with all billing and payor requirements.
Key Responsibilities:
Denial Resolution (Primary Focus)
- Investigate and resolve upheld and complex claim denials across all payors
- Perform root cause analysis to identify trends and recurring denial drivers
- Develop and submit appeals, reconsiderations, and supporting documentation
- Collaborate with clinical, intake, and billing teams to obtain necessary information for resolution
- Maintain tracking of high-dollar and aged denial cases through resolution
Payor Guidelines & Compliance
- Act as subject matter expert on payor billing rules, authorization requirements, and documentation standards
- Interpret and communicate payor policies to internal teams (billing, clinical, intake)
- Monitor updates to payor requirements and ensure timely internal implementation
- Support audits and ensure compliance with Medicaid and commercial payor regulations
Process Development & Optimization
- Identify gaps in current billing and collections workflows contributing to denials
- Design and implement standardized processes to improve clean claim rates
- Develop SOPs and internal guidance for billing best practices
- Partner with RCM Director to transition and strengthen in-house billing operations
Cross-Functional Collaboration
- Work closely with Clinical Directors, BCBAs, and Intake to resolve documentation or authorization-related denials
- Provide feedback loops to prevent future denials (e.g., documentation errors, credentialing issues)
- Support training initiatives for staff on billing compliance and documentation expectations
Reporting & Insights
- Track and report on denial trends, resolution timelines, and financial impact
- Identify opportunities to improve reimbursement and reduce revenue leakage
- Provide regular updates to RCM Director on high-priority issues and risks
Preferred Qualifications:
- Experience supporting or transitioning to in-house billing operations
- Prior experience working directly with payors on escalated issues
- Familiarity with multi-site healthcare or ABA organizations
Key Competencies:
- Detail-oriented with strong follow-through
- Ability to navigate complex payor systems and policies
- Process-driven mindset with a focus on continuous improvement
- Strong sense of ownership and accountability
- Ability to work cross-functionally and influence outcomes