Senior Healthcare Denials Program Leader

Outsourcey

Philippines

Remote

PHP 180,000 - 360,000

Full time

14 days+

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Job summary

Outsourcey in the Philippines seeks an accomplished leader to helm clinical denial management programs. You will develop strategies, oversee multiple teams, and align denial initiatives with revenue cycle objectives.

You will guide enterprise-wide medical necessity, DRG, and coding strategies, while driving automation and analytics to reduce revenue leakage. Join a growing BPO with strong client partnerships and executive visibility.

Qualifications

Bachelor’s degree in nursing, Healthcare Administration, Health Information Management, or related field.
Active RN license or applicable clinical credential.
7+ years in healthcare with clinical denials, CDI, RCM, or reimbursement.
3+ years of progressive leadership/management experience.
Experience with Epic, payer portals, denial analytics, and BI platforms.
Master's degree (MHA, MBA, MSN) or equivalent.
CDAS or equivalent denial management credential.
CCDS/CDIP or equivalent CDI certification.

Responsibilities

Develops and executes the strategic roadmap for clinical denial management programs.
Establishes program goals, KPIs, governance structures, and performance standards.
Oversees multiple teams, managers, and/or client programs.
Ensures alignment between clinical denial strategy and organizational revenue cycle objectives.
Develops standardized operating models, workflows, and best practices.
Owns program-level denial recovery and financial performance.
Monitors gross and net revenue opportunity, dollars at risk, recovery rate, overturn rate, and denial inventory.
Develops strategies to maximize reimbursement and reduce revenue leakage.
Supports financial forecasting, business cases, and resource planning.
Identifies opportunities for automation, technology, and workflow optimization.
Clinical Denial Strategy
Provides subject-matter leadership for complex clinical denial categories.
Establishes enterprise strategies for medical necessity, DRG, level-of-care, clinical validation, documentation, and payer-specific denials.
Reviews emerging payer policies and reimbursement changes.
Develops strategies for high-value and systemic denial issues.
Partners with clinical and revenue cycle leadership to address root causes.
Client & Executive Management
Serves as senior operational contact for assigned clients and programs.
Leads executive-level business reviews and performance discussions.
Presents program performance, financial outcomes, trends, risks, and strategic recommendations.
Manages client expectations and escalations.
Identifies opportunities for program expansion and additional value creation.
Denial Prevention & Transformation
Uses data analytics to identify systemic denial drivers.
Partners with CDI, HIM, coding, utilization management, clinical operations, finance, and billing leadership.
Develops corrective action and prevention strategies.
Measures the financial and operational impact of prevention initiatives.
Leads transformation projects involving technology, analytics, automation, and workflow redesign.
People & Organizational Leadership
Provides leadership to Managers, Team Leads, and clinical denial professionals, a team size of minimum 50+.
Establishes leadership development and succession-planning strategies.
Promotes a culture of accountability, continuous improvement, and client service.
Ensures appropriate staffing models and organizational structures.
Oversees competency and training programs.
Compliance & Risk Management
Ensures programs operate in accordance with regulatory requirements, payer policies, contractual obligations, and organizational standards.
Monitors emerging regulatory and reimbursement changes.
Identifies operational and financial risks and develops mitigation strategies.