[Hiring] RCM Denials & Payor Compliance Specialist @Academy ABA
Role Description
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
ā¢ Denial Resolution (Primary Focus)
ā¢ Investigate and resolve upheld and complex claim denials across all payors
ā¢ Perform root cause analysis to identify trends and recurring denial drivers
ā¢ Develop and submit appeals, reconsiderations, and supporting documentation
ā¢ Collaborate with clinical, intake, and billing teams to obtain necessary information for resolution
ā¢ Maintain tracking of high-dollar and aged denial cases through resolution
ā¢ Payor Guidelines & Compliance
ā¢ Act as subject matter expert on payor billing rules, authorization requirements, and documentation standards
ā¢ Interpret and communicate payor policies to internal teams (billing, clinical, intake)
ā¢ Monitor updates to payor requirements and ensure timely internal implementation
ā¢ Support audits and ensure compliance with Medicaid and commercial payor regulations
ā¢ Process Development & Optimization
ā¢ Identify gaps in current billing and collections workflows contributing to denials
ā¢ Design and implement standardized processes to improve clean claim rates
ā¢ Develop SOPs and internal guidance for billing best practices
ā¢ Partner with RCM Director to transition and strengthen in-house billing operations
ā¢ Cross-Functional Collaboration
ā¢ Work closely with Clinical Directors, BCBAs, and Intake to resolve documentation or authorization-related denials
ā¢ Provide feedback loops to prevent future denials (e.g., documentation errors, credentialing issues)
ā¢ Support training initiatives for staff on billing compliance and documentation expectations
ā¢ Reporting & Insights
ā¢ Track and report on denial trends, resolution timelines, and financial impact
ā¢ Identify opportunities to improve reimbursement and reduce revenue leakage
ā¢ Provide regular updates to RCM Director on high-priority issues and risks
Qualifications
ā¢ 3+ years of experience in healthcare revenue cycle management, preferably in ABA or behavioral health
ā¢ Strong experience with denial management, appeals, and payor communications
ā¢ Knowledge of Medicaid and commercial insurance billing requirements
ā¢ Familiarity with CPT codes relevant to ABA services (e.g., 97151, 97153, 97155, etc.)
ā¢ Experience working with EMR systems (CentralReach preferred)
ā¢ Strong analytical and problem-solving skills
ā¢ Excellent written and verbal communication skills
Preferred Qualifications
ā¢ Experience supporting or transitioning to in-house billing operations
ā¢ Prior experience working directly with payors on escalated issues
ā¢ Familiarity with multi-site healthcare or ABA organizations
Key Competencies
ā¢ Detail-oriented with strong follow-through
ā¢ Ability to navigate complex payor systems and policies
ā¢ Process-driven mindset with a focus on continuous improvement
ā¢ Strong sense of ownership and accountability
ā¢ Ability to work cross-functionally and influence outcomes
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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
ā¢ Denial Resolution (Primary Focus)
ā¢ Investigate and resolve upheld and complex claim denials across all payors
ā¢ Perform root cause analysis to identify trends and recurring denial drivers
ā¢ Develop and submit appeals, reconsiderations, and supporting documentation
ā¢ Collaborate with clinical, intake, and billing teams to obtain necessary information for resolution
ā¢ Maintain tracking of high-dollar and aged denial cases through resolution
ā¢ Payor Guidelines & Compliance
ā¢ Act as subject matter expert on payor billing rules, authorization requirements, and documentation standards
ā¢ Interpret and communicate payor policies to internal teams (billing, clinical, intake)
ā¢ Monitor updates to payor requirements and ensure timely internal implementation
ā¢ Support audits and ensure compliance with Medicaid and commercial payor regulations
ā¢ Process Development & Optimization
ā¢ Identify gaps in current billing and collections workflows contributing to denials
ā¢ Design and implement standardized processes to improve clean claim rates
ā¢ Develop SOPs and internal guidance for billing best practices
ā¢ Partner with RCM Director to transition and strengthen in-house billing operations
ā¢ Cross-Functional Collaboration
ā¢ Work closely with Clinical Directors, BCBAs, and Intake to resolve documentation or authorization-related denials
ā¢ Provide feedback loops to prevent future denials (e.g., documentation errors, credentialing issues)
ā¢ Support training initiatives for staff on billing compliance and documentation expectations
ā¢ Reporting & Insights
ā¢ Track and report on denial trends, resolution timelines, and financial impact
ā¢ Identify opportunities to improve reimbursement and reduce revenue leakage
ā¢ Provide regular updates to RCM Director on high-priority issues and risks
Qualifications
ā¢ 3+ years of experience in healthcare revenue cycle management, preferably in ABA or behavioral health
ā¢ Strong experience with denial management, appeals, and payor communications
ā¢ Knowledge of Medicaid and commercial insurance billing requirements
ā¢ Familiarity with CPT codes relevant to ABA services (e.g., 97151, 97153, 97155, etc.)
ā¢ Experience working with EMR systems (CentralReach preferred)
ā¢ Strong analytical and problem-solving skills
ā¢ Excellent written and verbal communication skills
Preferred Qualifications
ā¢ Experience supporting or transitioning to in-house billing operations
ā¢ Prior experience working directly with payors on escalated issues
ā¢ Familiarity with multi-site healthcare or ABA organizations
Key Competencies
ā¢ Detail-oriented with strong follow-through
ā¢ Ability to navigate complex payor systems and policies
ā¢ Process-driven mindset with a focus on continuous improvement
ā¢ Strong sense of ownership and accountability
ā¢ Ability to work cross-functionally and influence outcomes
Apply tot his job
Apply To this Job