RCM Denials & Payor Compliance Specialist

This a Full Remote job, the offer is available from: Georgia (USA) 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 This offer from "Academy ABA" has been enriched by Jobgether.com and got a 72% flex score.