Job Description
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