Manager, Denial Prevention, Trends and Audits

SUMMARY:
The Manager, Denial Prevention, Trends and Audits is a critical Revenue Cycle leadership role responsible for converting denial and audit activity from a reactive, transactional queue into a proactive, analytics-driven program that identifies Hospital Billing (HB) denial trends, diagnoses root cause, and drives targeted, timeline-bound solutions in partnership with every area that touches the HB claim life cycle — Patient Access/Financial Clearance, HB Coding & CDI, Revenue Integrity, Contracting, Case Management/UR, the Epic Optimization Team, and clinical departments.
This role owns day-to-day operational performance of the non-clinical HB denial and audit team (technical, administrative, and eligibility/authorization-related denials and audit coordination) and serves as the Revenue Cycle’s primary driver — working in close, ongoing partnership with Brown University Health’s Epic Optimization Team — for maximizing Epic HB system effectiveness: building system-based controls, automation, and standard work that prevent denials before submission, reduce manual rework, and reduce the training burden required to sustain the function. Clinical denial and appeal work (e.g., medical necessity, level-of-care) is managed within Revenue Integrity’s clinical appeal nursing team; this role is directly accountable for partnering with that team so clinical and technical denial strategies operate as one aligned program rather than two disconnected efforts.
Strong, hands-on Epic HB expertise is a core and non-negotiable requirement of this role. The manager must be able to read and interpret Epic HB work queue logic, claim edits, and BPA build well enough to translate front-line denial patterns into precise, actionable system change requests for the Epic Optimization Team, and to validate that delivered fixes actually close the gap.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
Denial Trend Identification & Root-Cause Analytics
Own HB denial trend intelligence: aggregate and analyze Hospital Billing denials by payer, reason/CARC-RARC code, service line, site of care, and root cause to separate one-off errors from recurring, systemic workflow failures.
Apply structured root-cause analysis (RCA): move beyond claim-level firefighting to population-level diagnosis — identifying the upstream scheduling, registration, authorization, documentation, coding, or system failure generating a denial cluster, not just the individual claim fix.
Build and maintain a denial trend dashboard: using Epic reporting tools (Cogito, SlicerDicer, Workbench/Radar) to visualize denial rate, volume, dollar impact, and recovery rate by category, payer, and accountable owner on a weekly/monthly/quarterly cadence.
Quantify impact to prioritize action: size each trend by dollars at risk, FTE hours consumed, and recurrence rate so cross-functional intervention is focused on the highest-value opportunities first.
Cross-Functional Partnership & Targeted Solution Development
Partner with every upstream and downstream stakeholder — Patient Access/Financial Clearance, HB Coding & CDI, Revenue Integrity, Contracting/Payer Strategy, Case Management/UR, the Epic Optimization Team, and clinical departments — to convert denial trend findings into targeted, root-cause-specific action plans.
Lead corrective action planning: for every significant trend, define the accountable owner, the proposed solution, and a committed implementation timeline; track progress to closure and validate the fix through post-implementation denial-rate monitoring.
Facilitate a recurring cross-functional denial governance forum: bring stakeholder owners together — including the Epic Optimization Team — to review open trends, agree on solutions, and hold owners to committed timelines, creating a single, shared accountability structure across Revenue Cycle, Epic, and clinical/operational partners.
Escalate systemic issues to leadership: with supporting data, quantified financial/operational impact, and a recommended resolution path when a fix requires executive sponsorship, payer engagement, or capital/system investment.
Epic Optimization & Systemic Controls
Serve as the primary Denial Prevention liaison to the Epic Optimization Team, translating recurring HB denial and audit patterns into concrete Epic build requests — work queue logic, claim edits, Best Practice Advisories (BPAs), medical necessity checks, real-time eligibility (RTE) and authorization edits, and charge/order routing rules.
Identify prevention-first system opportunities: use Epic functionality (work queue automation, auto-routing, edit rules, RTE, referral/authorization checks, denial-code mapping) to intercept root causes before claims are submitted, rather than remediate denials after the fact.
Partner directly with the Epic Optimization Team on testing, validation, and go-live support for every system change tied to HB denial prevention; monitor post-go-live performance to confirm the control is working as intended and quantify the resulting impact.
Build systemic and process controls (standard work, templates, system edit checks) that reduce reliance on manual review and rework, and reduce the volume and complexity of training required for staff to perform denial and audit functions.
Quantifiable Impact & Continuous Improvement
Establish and report against improvement targets, including: reduction in denial volume attributable to systemic/process fixes; reduction in manual touches per account; reduction in average new-hire training time driven by system automation and standard work; improvement in first-pass resolution rate; and reduction in preventable denial write-offs.
Maintain a solution tracker documenting each denial trend identified, its root cause, the corrective action taken, the accountable owner, the timeline, and the quantified outcome — for use in leadership and executive-level reporting.
Daily Operations & Work Queue Management
Oversee daily HB denial and audit work queues, ensuring proper distribution, prioritization, and timely follow-up.
Monitor staff productivity, account volumes, and aging to ensure adherence to established SLAs.
Ensure high-dollar and aging accounts are identified, prioritized, and escalated appropriately.
Conduct routine audits of staff work to validate accuracy of account review, documentation, and resolution actions.
Maintain clear guidelines for when accounts can be adjusted, escalated, or require additional review.
Denial Resolution Execution (Technical & Medical Necessity)
Manage the end-to-end technical/medical necessity HB denial and reconsideration process (e.g., eligibility, authorization, timely filing, coding/billing edits, coordination of benefits), ensuring timely submission and follow-up.
Ensure staff accurately review denial codes and payer correspondence, submit complete and compliant non-clinical appeal packages, and document all actions within the system.
Partner closely with Revenue Integrity’s clinical appeal nursing team to ensure seamless hand-off of clinically driven denials (e.g., medical necessity, level of care) and shared visibility into combined denial trend data across both teams.
Track and report on daily and weekly denial volumes, resolution rates, and backlog status; enforce accountability for timely filing deadlines and appeal turnaround times.
Audit Intake & Response Coordination
Oversee intake of all HB audit requests and ensure timely assignment and tracking.
Coordinate required documentation (medical records, coding validation, billing support) across departments.
Ensure all audit responses are submitted within payer/regulatory deadlines, and are complete, accurate, and properly documented.
Maintain a centralized audit tracker with status, due dates, and outcomes.
Quality Assurance & Documentation Standards
Implement and monitor standard work for account review and documentation.
Perform routine QA reviews to ensure appropriate denial categorization, complete account notes supporting decisions, and compliance with internal policies and audit requirements.
Provide real-time feedback and coaching to staff to improve quality and consistency.
Performance Management & Staff Oversight
Directly manage a team of non-clinical denial/audit specialists and analysts, including daily productivity monitoring, one-on-one check-ins and coaching, and performance evaluations and corrective action when needed.
Establish clear productivity and quality benchmarks (e.g., accounts worked per day, QA scores).
Coordinate onboarding and training for new hires, prioritizing system-driven, standard-work-based training that scales as automation and controls reduce manual complexity.
Reporting & Operational Metrics
Produce routine operational reports, including denial inventory and aging; appeals submitted and overturn rates; audit volumes, status, and outcomes; and high-dollar account tracking.
Highlight risks such as timely filing exposure, audit deadline risks, and backlog growth.
Provide actionable insights, trend findings, and clear next steps for leadership review, including progress against the solution tracker.
Performs other duties as assigned.
EDUCATION:
Bachelor’s degree required (Healthcare Administration, Business, Finance,