Director, Denial Management & Prevention

Take the lead in transforming denial management and prevention across a complex, multi-hospital healthcare system.

MedStar Health is seeking a strategic and results-driven Director of Denial Management & Prevention to lead systemwide initiatives that strengthen revenue integrity, reduce preventable denials, and optimize reimbursement performance.

In this highly collaborative leadership role, you will partner directly with the Vice President of Clinical Resource Management and key organizational leaders to develop and execute innovative strategies addressing technical, clinical, and medical necessity denials and appeals.

This is an opportunity to move beyond traditional denial management and play a pivotal role in shaping proactive prevention strategies, leveraging data and technology, and driving sustainable operational improvements across our hospitals.

What You'll Lead

• Systemwide Denial Prevention Strategy: Develop and execute initiatives to reduce preventable denials, strengthen reimbursement processes, and improve financial outcomes across the health system.

• Appeals Management & Recovery: Provide strategic oversight of clinical and technical appeals operations, including vendor performance, recovery opportunities, and process optimization.

• Executive Collaboration: Partner with senior leaders across Clinical Resource Management, Revenue Cycle, Managed Care, and hospital operations to identify opportunities and implement sustainable improvements.

• Data-Driven Performance Improvement: Leverage analytics, dashboards, industry benchmarks, and denial trends to establish performance goals, monitor outcomes, and guide strategic decisions.

• Clinical & Operational Integration: Collaborate with Acute Case Management teams to improve workflows, strengthen documentation practices, and advance education initiatives that support denial prevention.

• Payer Strategy & Reimbursement Optimization: Work closely with Managed Care and reimbursement teams to identify payer-related challenges, address denial trends, and improve financial performance.

• Regulatory Compliance & Operational Excellence: Partner with Corporate Compliance and other stakeholders to ensure denial and appeals processes align with applicable regulations and organizational standards.

• Technology & Vendor Optimization: Champion technology-enabled solutions that improve efficiency, strengthen reporting capabilities, and hold external partners accountable for performance.

Primary Duties and Responsibilities

• Collaborates with VP Clinical Resource Management and other leaders to identify denial mitigation opportunities and reimbursement improvement processes.
• Oversees and directs appeals for the system to include oversight of any appeal vendors.
• Partners with system leaders to create implement and sustain improvements that contribute to the organization's goals.
• Provides strategic direction and clinical oversight for hospital denials and appeal operations and outcomes.
• Works with organization leaders to develop performance goals and objectives based on industry best practices and system benchmarks.
• Develops and maintains analytics and dashboards to standardize entity denial summaries.
• Supports system denial mitigation projects and serves as a consultant for individual entities regarding denial trends and interventions.
• Works with Acute Case Management teams focusing on operational improvements and team education to support denial reduction.
• Collaborates with the Managed Care team to summarize and address payer opportunities.
• Works with Corporate Compliance and Rates and Reimbursement team to ensure operations and policies conform to current governmental and state regulations.
• Manages business partner/vendor contracts holding them accountable to contractual obligations and both industry and organizational benchmarks.
• Supports the optimization of technology to enhance operational efficiency and improve reimbursement.

Minimal Qualifications
Education

• Bachelor's degree Nursing Finance Accounting or Healthcare Administration required

Experience

• 5-7 years of Revenue Cycle experience including appeals and financial clearance required and
• Leadership experience in the healthcare industry with emphasis on revenue cycle preferred

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure preferred

Knowledge Skills and Abilities

• Team builder with excellent interpersonal skills
• Strong analytical and problem-solving skills with high level of accuracy and attention to detail.
• Strong verbal and written communication skills including presentation skills with ability to effectively interact with all levels of management internal departments and external agencies.
• Computer skills are required to be efficient in managing data (Word PowerPoint Excel and email programs). Advance Microsoft Excel skills.