RCM Denials & Payor Compliance Specialist

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

Qualifications:

• 3 years of experience in healthcare revenue cycle management, preferably in ABA or behavioral health
• Strong experience with denial management, appeals, and payor communications
• Knowledge of Medicaid and commercial insurance billing requirements
• Familiarity with CPT codes relevant to ABA services (e.g., 97151, 97153, 97155, etc.)
• Experience working with EMR systems (CentralReach preferred)
• Strong analytical and problem-solving skills
• Excellent written and verbal communication skills