Senior Complex Denials Consultant

R1 is the leading provider of technology-driven solutions that transform the patient experience and financial performance of hospitals, health systems and medical groups. We are the one company that combines the deep expertise of a global workforce of revenue cycle professionals with the industry’s most advanced technology platform, encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration. 

As our Senior Complex Denials Consultant, you will represent and counsel healthcare providers in their disputes with medical insurance carriers and managed care organizations at all stages of the administrative appeals process. Every day, you will handle contract review and appeal template development based on contractual provisions and applicable state and federal laws, writing appeals and letters to insurance companies to resolve denials, and reviewing high-balance or complex accounts, and providing oversight of Complex Denials Consultants within the region/pod of assigned accounts.

To thrive in this role, you must maintain a foundational understanding of Commercial, Governmental, Managed Care, and ERISA regulations regarding payment, coverage, conditions of participation, and other relevant topics. You will initiate training of recovery staff team members and provide necessary feedback as requested by management.  You will also have performance standards and goals as set by management, including timelines for initial reviews, follow-up tasks, documentation requests, and project assignments.

Here’s what you will experience working as a Senior Complex Denials Consultant:

• Assist recovery staff in pursuing appeals, including the development of new and innovative legal and procedural arguments and tools.

• Oversee and draft complex contractual appeals and letters to insurance companies.

• Review and apply client contract language and rates to resolve denied claims.

• Utilize payer-provider and administrative manuals to dispute denied claims.

• Contact provider representatives or higher-level resolution units to resolve complex claim and appeal issues.

• Represent clients during Administrative Law Judge hearings as needed.

• Assist with the training and mentoring of recovery staff team members and provide necessary feedback as requested by management.

• Apply provider-specific reimbursement methodologies, payment policies, and provider contracts to confirm payment in full.

• Audit teams weekly for compliance with general expectations for productivity and compliance with deadlines as set for the entire legal team.

• Responsible for attending all scheduled Internal High Balance Meeting Calls for their assigned areas and/or providing to the Director a full report prior to these meetings on the status of accounts supervised by their respective teams.

• Manage projects and oversee assigned weekly activities, ensuring effective mentoring and development of team members.

• Serve as an exemplar for the team by consistently meeting and exceeding key performance indicators (KPIs), setting a standard for excellence and accountability.

Required Skills:

• Law degree from an accredited college or university with experience practicing healthcare law and/or organizational law experience.

• Admitted to practice law in any state.

The healthcare system is always evolving — and it’s up to us to use our shared expertise to find new solutions that can keep up. On our growing team you’ll find the opportunity to constantly learn, collaborate across groups and explore new paths for your career.

Our associates are given the chance to contribute, think boldly and create meaningful work that makes a difference in the communities we serve around the world. We go beyond expectations in everything we do. Not only does that drive customer success and improve patient care, but that same enthusiasm is applied to giving back to the community and taking care of our team — including offering a competitive benefits package.

R1 RCM Inc. (“the Company”) is dedicated to the fundamentals of equal employment opportunity. The Company’s employment practices , including those regarding recruitment, hiring, assignment, promotion, compensation, benefits, training, discipline, and termination shall not be based on any person’s age, color, national origin, citizenship status, physical or mental disability, medical condition, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status or any other characteristic protected by federal, state or local law. Furthermore, the Company is dedicated to providing a workplace free from harassment based on any of the foregoing protected categories.

If you have a disability and require a reasonable accommodation to complete any part of the job application process, please contact us at 312-496-7709 for assistance.

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To learn more, visit: R1RCM.com

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