Reimbursement & Appeals Supervisor - 21516
hace 6 días
Carlsbad
Job Description Reimbursement & Appeals Supervisor - Simply Biotech OVERVIEW Are you looking for a new career opportunity with an exciting biotech company?! Then we have got the right team for you! In this role, you are responsible for the duties listed below. Immediate opening for a Reimbursement & Appeals Supervisor in Carlsbad, CA who possesses: • 5+ years of progressive healthcare revenue cycle experience with hands-on responsibility for back-end denials, appeals, payer follow-up, reimbursement, or revenue recovery, • 2+ years of direct supervisory or formal team leadership experience in a healthcare business office, revenue cycle, laboratory, hospital, physician, or payer-facing environment, • Experience managing multiple denial categories and appeal levels across commercial and government payers, • Advanced Excel experience and comfort using billing systems, reporting tools, and payer portals FULL DESCRIPTION: We are seeking a Reimbursement & Appeals Supervisor to provide direct leadership for back-end revenue cycle operations focused on payer denials, appeals, reimbursement, revenue recovery, and payer follow-up. This role is responsible for overseeing daily work distribution, staff performance, appeal quality and timeliness, reimbursement barriers, denial trends, reporting, root-cause analysis, corrective action plans, and cross-functional process improvement. The ideal candidate will have strong healthcare revenue cycle experience, hands-on denials and appeals experience, leadership experience, advanced Excel skills, payer policy knowledge, and the ability to translate reimbursement trends into operational improvements. The selected candidate will be responsible for: • Overseeing daily denial, appeal, payer follow-up, and reimbursement recovery activities, • Prioritizing work by filing deadline, appeal level, balance, aging, payer requirements, and likelihood of recovery, • Directing the review and resolution of complex denials, • Supporting denials related to medical necessity, coding, bundling, modifiers, timely filing, documentation, reimbursement, and related issues, • Ensuring appeals are accurate, complete, persuasive, supported by applicable records and payer policy, and submitted within contractual or regulatory timeframes, • Guiding escalation through payer-specific reconsideration, external review, administrative, regulatory, and other dispute pathways when appropriate, • Monitoring appeal inventory, aging, overturn rates, recovered revenue, upheld denials, write-offs, and unresolved payer issues, • Reviewing underpayments and reimbursement variances, • Coordinating corrective action and payer escalation when payments do not align with applicable terms, policies, or expected reimbursement, • Maintaining effective controls for appeal tracking, follow-up dates, correspondence, evidence, outcomes, and final account disposition, • Analyzing denial and reimbursement data to identify recurring payer, process, documentation, coding, authorization, and system-related trends, • Performing root-cause analysis and developing measurable corrective action plans, • Addressing both recovery of affected claims and prevention of future denials, • Partnering with front-end billing, coding, patient relations, provider support, market access, laboratory operations, finance, compliance, and technology teams, • Resolving upstream and downstream revenue cycle issues, • Recommending and implementing workflow, system, worklist, reporting, and documentation improvements, • Maintaining current standard operating procedures, work instructions, appeal templates, payer reference materials, and escalation pathways, • Providing direct supervision, coaching, and development to assigned staff, • Managing workload, attendance, productivity, quality, professional conduct, and completion of assigned responsibilities, • Establishing clear individual and team expectations, production standards, quality measures, and follow-up requirements, • Conducting regular one-on-one meetings, team meetings, performance reviews, and documented coaching conversations, • Addressing performance or behavioral concerns objectively and consistently in partnership with leadership and Human Resources, • Supporting billing leads and subject-matter experts with training, work review, quality audits, corrective action, and knowledge development, • Creating a collaborative and accountable work environment, • Planning coverage and redistributing work as necessary based on volume fluctuations, absences, payer deadlines, and urgent escalations, • Preparing and analyzing weekly and monthly operational reports for leadership, • Reporting on denial volume, denial rate, aging, appeal inventory, overturn rate, recovered revenue, productivity, quality, and payer-specific risk, • Using reporting to distinguish isolated errors from systemic issues, • Identifying affected workflows, populations, financial exposure, and required corrective action, • Monitoring accounts receivable and payer worklists to ensure timely, accurate follow-up and appropriate account resolution, • Communicating material trends, operational risks, payer issues, and recommended actions to leadership and cross-functional stakeholders, • Participating in projects, audits, test launches, system implementations, and payer initiatives that affect reimbursement or denial risk, • Communicating effectively across in-person and virtual environments, • Using Outlook, Microsoft Teams, Zoom, shared documents, spreadsheets, reporting tools, billing systems, and payer portals, • Facilitating meetings with clear objectives, decisions, owners, and due dates, • Handling escalated payer, provider, patient, and internal stakeholder concerns professionally and accurately, • Ensuring denial, appeal, reimbursement, and account resolution activities comply with applicable requirements, payer guidelines, contractual obligations, organizational policies, and privacy standards, • Remaining current on payer policies, reimbursement requirements, appeal rights, coding and billing guidance, and relevant industry developments, • Ensuring staff maintain complete, accurate, and audit-ready account documentation, • Protecting confidential patient, provider, employee, payer, and company information, • Performing other duties as assigned The selected candidate will also possess: • 2+ years of direct supervisory or formal team leadership experience required, • Supervisory or leadership experience in a healthcare business office, revenue cycle, laboratory, hospital, physician, or payer-facing environment required, • 5+ years of progressive healthcare revenue cycle experience required, • Hands-on experience with back-end denials, appeals, payer follow-up, reimbursement, or revenue recovery required, • Experience managing multiple denial categories and appeal levels across commercial and government payers required, • Working knowledge of payer policies and claim adjudication required, • Knowledge of medical necessity, authorization and referral requirements, coding-related denials, timely filing, reimbursement methodologies, and appeal documentation required, • Experience using denial and reimbursement metrics to identify trends, quantify financial impact, develop corrective actions, and monitor results required, • Demonstrated ability to coach employees, manage performance, establish accountability, and develop staff required, • Strong analytical, critical-thinking, investigation, and problem-solving skills required, • Strong attention to detail and follow-through required, • Clear and professional written, verbal, listening, and presentation skills required, • Experience communicating with leaders and cross-functional stakeholders required, • Advanced Microsoft Excel skills required, • Comfort using Outlook, Microsoft Teams, Zoom, shared-document platforms, billing systems, reporting tools, and multiple payer portals required, • Ability to organize competing priorities and meet payer deadlines, • Ability to remain calm under pressure and lead effectively in a high-volume environment, • Experience in laboratory, diagnostic, specialty, hospital, or physician revenue cycle operations preferred, • Experience with Medicare, Medicare Advantage, Medicaid, TRICARE, Veterans Affairs or Community Care Network, and commercial payer appeals preferred, • Experience with complex medical necessity appeals, external review, administrative escalation, regulatory complaints, or payer dispute resolution preferred, • Knowledge of underpayment identification, reimbursement variance analysis, payer contracts, fee schedules, or reimbursement modeling preferred, • Relevant certification in revenue cycle, healthcare finance, coding, billing, compliance, or leadership preferred, • Ability to work in Carlsbad, CA, • Ability to support a full-time opportunity Physical Requirements: • Ability to sit and work at a computer for extended periods, • Ability to stand, walk, speak, hear, and communicate throughout the workday, • Ability to communicate by phone, email, video meeting, and in person throughout the workday, • Ability to review denial reports, appeal documentation, reimbursement data, payer policies, account records, correspondence, billing systems, spreadsheets, operational reports, and computer screens for extended periods, • Ability to use hands and fingers for typing, data entry, reporting, documentation, spreadsheet work, and standard office tasks, • Ability to maintain close vision, adjust focus, and sustain viewing of computer monitors, • Ability to occasionally stand, walk, bend, reach, and move throughout the office as needed, • Ability to occasionally lift, carry, or move up to 40 pounds, • Ability to work in a standard office or approved remote-work environment, as applicable Salary Range: $75,000 to $85,000/year More information can be found at www.simplybiotech.com. \nCompany Description Simply Biotech was founded in 2008 and has been repeatedly recognized as one of San Diego County's fastest growing businesses. In 2025, we were named Business Journal's 'Best Places to Work'. Even as our competitors are scaling back and laying off staff, Simply Biotech is expanding to new markets and hiring additional staff in existing offices. Simply Biotech was founded in 2008 and has been repeatedly recognized as one of San Diego County's fastest growing businesses. In 2025, we were named Business Journal's 'Best Places to Work'. Even as our competitors are scaling back and laying off staff, Simply Biotech is expanding to new markets and hiring additional staff in existing offices.
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