Location: Philippines

About Us:

HBiz is a leading Revenue Cycle Management (RCM) company dedicated to helping healthcare providers optimize their financial performance. We specialize in delivering innovative solutions that streamline revenue cycle operations and enhance overall revenue generation for healthcare organizations. Our mission is to empower healthcare providers with the tools and expertise needed to maximize revenue, reduce operational costs, and improve patient care.

Job Summary:

We are seeking a highly motivated and experienced Clinical Case Management Nurse to join our team. The Clinical Case Management Nurse will play a crucial role in supporting our clients in the healthcare industry by providing expert clinical guidance, facilitating effective case management, and ensuring revenue cycle efficiency. This position offers a unique opportunity to combine clinical expertise with revenue cycle management knowledge.

Key Responsibilities:

• Clinical Assessment: Conduct comprehensive clinical assessments to determine the patient's medical condition, healthcare needs, and treatment options.
• Patient Advocacy: Serve as an advocate for patients by ensuring they receive appropriate care, coordinating with healthcare providers, and assisting in the resolution of healthcare-related issues.
• Care Coordination: Collaborate with interdisciplinary healthcare teams to coordinate patient care and treatment plans, ensuring the most cost-effective and clinically appropriate care is provided.
• Revenue Cycle Management: Utilize clinical expertise to support revenue cycle processes, including accurate coding, documentation improvement, and compliance with healthcare regulations.
• Utilization Review: Evaluate the necessity and appropriateness of healthcare services and assist in the management of length of stay, ensuring that healthcare resources are used efficiently.
• Documentation Improvement: Identify opportunities for improving clinical documentation to support accurate coding and billing processes, ultimately improving reimbursement.
• Patient Education: Educate patients and their families about healthcare options, treatment plans, and financial responsibilities, helping to promote informed decision-making.
• Quality Assurance: Ensure the quality of care provided meets or exceeds established standards and that clinical documentation accurately reflects the patient's condition and care provided.
• Data Analysis: Analyze clinical and financial data to identify trends, opportunities for improvement, and areas of potential cost savings for clients.
• Compliance: Stay up-to-date with healthcare regulations, guidelines, and policies to ensure all patient care and revenue cycle processes are in compliance with industry standards.

Qualifications:

Registered Nurse (RN) licensure in the state of practice.

Bachelor of Science in Nursing (BSN) preferred.

Case Management Certification (e.g., CCM) is a plus.

Minimum of 2 years of clinical nursing experience, preferably in a hospital or acute care setting.

Strong understanding of revenue cycle management and healthcare reimbursement.

Proficiency in medical coding and clinical documentation improvement.

Excellent communication, interpersonal, and teamwork skills.

Ability to work independently and make sound clinical and financial decisions.

Strong analytical and problem-solving skills.

Proficient in using healthcare information systems and technology.

Commitment to maintaining patient confidentiality and ethical standards.

Benefits:

Competitive salary

Comprehensive healthcare benefits

Professional development and training opportunities

Collaborative and supportive work environment

Opportunities for advancement within the company

Work-life balance programs

If you are a skilled Clinical Case Management Nurse who is passionate about enhancing patient care and optimizing revenue cycle processes, we encourage you to apply for this exciting opportunity with Hbiz. Join us in making a positive impact on the healthcare industry and helping healthcare providers thrive financially while providing top-notch patient care.

**** Salaries from 60,000 to 90,000 PhP per month depending on experience******

Key Responsibilities:

1. Review and analyze clinical documentation, utilization records, and insurance denial rationales to formulate well-constructed appeal cases.
2. Engage in the appeals process for denied claims, ensuring that all appeals are submitted in a timely manner according to regulatory and insurer-specific requirements.
3. Utilize clinical experience and knowledge in accordance with established Milliman or Interqual guidelines to substantiate medical necessity and appropriate level of care.
4. Collaborate with healthcare providers, case managers, and insurance companies to gather additional information and advocate for proper patient services and reimbursement.
5. Interpret and apply ICD-10 coding in the review of medical records to support appeal submissions.
6. Maintain accurate and detailed records of all appeals processes, outcomes, and communications.
7. Educate clinical staff on best practices, changes in payer requirements, and implications of clinical documentation and coding standards.
8. Stay abreast of changes in healthcare regulations, payer policies, and clinical criteria guiding medical necessity.

Required Qualifications:

• Active Registered Nurse (RN) license in the Philippines, US licensed preferred
• Minimum of two years of bedside clinical experience in a hospital setting.
• At least one year of experience in clinical appeals or utilization management.
• Bachelor’s Degree in Nursing (BSN) preferred; minimum of an Associate Degree in Nursing (ADN) required.
• Proficiency with Milliman or Interqual clinical guidelines.
• Strong understanding of ICD-10 coding principles.
• Excellent written communication skills, with the ability to articulate complex clinical information in a clear and professional manner for appeal justifications.
• Strong organizational skills and the ability to manage multiple cases simultaneously.

Desired Skills:

• Exceptional critical thinking and problem-solving skills.
• Demonstrated ability to work independently as well as part of a team.
• Commitment to ethical medical practices and compliance with all federal and state regulations.

What We Offer:

• Competitive salary and benefits package including health and paid time off.
• Opportunities for professional growth and continuing education.
• Supportive work environment focused on teamwork and positive outcomes.
• HBiz is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
• We look forward to considering your application and hopefully welcoming you to our team!

**** Salaries from 60,000 to 90,000 PhP per month depending on experience******

Key Responsibilities:

1. Review and analyze clinical documentation, utilization records, and insurance denial rationales to formulate well-constructed appeal cases.
2. Engage in the appeals process for denied claims, ensuring that all appeals are submitted in a timely manner according to regulatory and insurer-specific requirements.
3. Utilize clinical experience and knowledge in accordance with established Milliman or Interqual guidelines to substantiate medical necessity and appropriate level of care.
4. Collaborate with healthcare providers, case managers, and insurance companies to gather additional information and advocate for proper patient services and reimbursement.
5. Interpret and apply ICD-10 coding in the review of medical records to support appeal submissions.
6. Maintain accurate and detailed records of all appeals processes, outcomes, and communications.
7. Educate clinical staff on best practices, changes in payer requirements, and implications of clinical documentation and coding standards.
8. Stay abreast of changes in healthcare regulations, payer policies, and clinical criteria guiding medical necessity.

Required Qualifications:

• Active Registered Nurse (RN) license in the Philippines, US licensed preferred
• Minimum of two years of bedside clinical experience in a hospital setting.
• At least one year of experience in clinical appeals or utilization management.
• Bachelor’s Degree in Nursing (BSN) preferred; minimum of an Associate Degree in Nursing (ADN) required.
• Proficiency with Milliman or Interqual clinical guidelines.
• Strong understanding of ICD-10 coding principles.
• Excellent written communication skills, with the ability to articulate complex clinical information in a clear and professional manner for appeal justifications.
• Strong organizational skills and the ability to manage multiple cases simultaneously.

Desired Skills:

• Exceptional critical thinking and problem-solving skills.
• Demonstrated ability to work independently as well as part of a team.
• Commitment to ethical medical practices and compliance with all federal and state regulations.

What We Offer:

• Competitive salary and benefits package including health and paid time off.
• Opportunities for professional growth and continuing education.
• Supportive work environment focused on teamwork and positive outcomes.
• HBiz is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
• We look forward to considering your application and hopefully welcoming you to our team!

**** Salaries from 60,000 to 90,000 PhP per month depending on experience******

Key Responsibilities:

1. Review and analyze clinical documentation, utilization records, and insurance denial rationales to formulate well-constructed appeal cases.
2. Engage in the appeals process for denied claims, ensuring that all appeals are submitted in a timely manner according to regulatory and insurer-specific requirements.
3. Utilize clinical experience and knowledge in accordance with established Milliman or Interqual guidelines to substantiate medical necessity and appropriate level of care.
4. Collaborate with healthcare providers, case managers, and insurance companies to gather additional information and advocate for proper patient services and reimbursement.
5. Interpret and apply ICD-10 coding in the review of medical records to support appeal submissions.
6. Maintain accurate and detailed records of all appeals processes, outcomes, and communications.
7. Educate clinical staff on best practices, changes in payer requirements, and implications of clinical documentation and coding standards.
8. Stay abreast of changes in healthcare regulations, payer policies, and clinical criteria guiding medical necessity.

Required Qualifications:

• Active Registered Nurse (RN) license in the Philippines, US licensed preferred
• Minimum of two years of bedside clinical experience in a hospital setting.
• At least one year of experience in clinical appeals or utilization management.
• Bachelor’s Degree in Nursing (BSN) preferred; minimum of an Associate Degree in Nursing (ADN) required.
• Proficiency with Milliman or Interqual clinical guidelines.
• Strong understanding of ICD-10 coding principles.
• Excellent written communication skills, with the ability to articulate complex clinical information in a clear and professional manner for appeal justifications.
• Strong organizational skills and the ability to manage multiple cases simultaneously.

Desired Skills:

• Exceptional critical thinking and problem-solving skills.
• Demonstrated ability to work independently as well as part of a team.
• Commitment to ethical medical practices and compliance with all federal and state regulations.

What We Offer:

• Competitive salary and benefits package including health and paid time off.
• Opportunities for professional growth and continuing education.
• Supportive work environment focused on teamwork and positive outcomes.
• HBiz is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
• We look forward to considering your application and hopefully welcoming you to our team!

Location: Philippines

About Us:

HBiz is a leading Revenue Cycle Management (RCM) company dedicated to helping healthcare providers optimize their financial performance. We specialize in delivering innovative solutions that streamline revenue cycle operations and enhance overall revenue generation for healthcare organizations. Our mission is to empower healthcare providers with the tools and expertise needed to maximize revenue, reduce operational costs, and improve patient care.

Job Summary:

We are seeking a highly motivated and experienced Clinical Case Management Nurse to join our team. The Clinical Case Management Nurse will play a crucial role in supporting our clients in the healthcare industry by providing expert clinical guidance, facilitating effective case management, and ensuring revenue cycle efficiency. This position offers a unique opportunity to combine clinical expertise with revenue cycle management knowledge.

Key Responsibilities:

• Clinical Assessment: Conduct comprehensive clinical assessments to determine the patient's medical condition, healthcare needs, and treatment options.
• Patient Advocacy: Serve as an advocate for patients by ensuring they receive appropriate care, coordinating with healthcare providers, and assisting in the resolution of healthcare-related issues.
• Care Coordination: Collaborate with interdisciplinary healthcare teams to coordinate patient care and treatment plans, ensuring the most cost-effective and clinically appropriate care is provided.
• Revenue Cycle Management: Utilize clinical expertise to support revenue cycle processes, including accurate coding, documentation improvement, and compliance with healthcare regulations.
• Utilization Review: Evaluate the necessity and appropriateness of healthcare services and assist in the management of length of stay, ensuring that healthcare resources are used efficiently.
• Documentation Improvement: Identify opportunities for improving clinical documentation to support accurate coding and billing processes, ultimately improving reimbursement.
• Patient Education: Educate patients and their families about healthcare options, treatment plans, and financial responsibilities, helping to promote informed decision-making.
• Quality Assurance: Ensure the quality of care provided meets or exceeds established standards and that clinical documentation accurately reflects the patient's condition and care provided.
• Data Analysis: Analyze clinical and financial data to identify trends, opportunities for improvement, and areas of potential cost savings for clients.
• Compliance: Stay up-to-date with healthcare regulations, guidelines, and policies to ensure all patient care and revenue cycle processes are in compliance with industry standards.

Qualifications:

Registered Nurse (RN) licensure in the state of practice.

Bachelor of Science in Nursing (BSN) preferred.

Case Management Certification (e.g., CCM) is a plus.

Minimum of 2 years of clinical nursing experience, preferably in a hospital or acute care setting.

Strong understanding of revenue cycle management and healthcare reimbursement.

Proficiency in medical coding and clinical documentation improvement.

Excellent communication, interpersonal, and teamwork skills.

Ability to work independently and make sound clinical and financial decisions.

Strong analytical and problem-solving skills.

Proficient in using healthcare information systems and technology.

Commitment to maintaining patient confidentiality and ethical standards.

Benefits:

Competitive salary

Comprehensive healthcare benefits

Professional development and training opportunities

Collaborative and supportive work environment

Opportunities for advancement within the company

Work-life balance programs

If you are a skilled Clinical Case Management Nurse who is passionate about enhancing patient care and optimizing revenue cycle processes, we encourage you to apply for this exciting opportunity with Hbiz. Join us in making a positive impact on the healthcare industry and helping healthcare providers thrive financially while providing top-notch patient care.

The Manager of Revenue Cycle Operations is responsible for overseeing and managing all aspects of the revenue cycle process to maximize efficiency and revenue for the healthcare organization. This role involves coordinating various functions, including billing, coding, claims processing, collections, and payment posting, to ensure the financial health of the organization. The Manager will also develop and implement strategies to improve revenue cycle performance, enhance patient satisfaction, and ensure compliance with regulations.

Key Responsibilities:

1. Leadership:
   • Provide leadership and direction to the revenue cycle team, including billing, coding, claims, collections, and payment posting staff.
   • Recruit, train, and develop team members to ensure high performance and professional growth.
   • Conduct regular performance evaluations and provide feedback and coaching to team members.
2. Revenue Cycle Optimization:
   • Develop and implement strategies to improve revenue cycle processes and increase efficiency.
   • Monitor key performance indicators (KPIs) and develop action plans to address areas of improvement.
   • Utilize data analytics to identify trends, issues, and opportunities for revenue enhancement.
3. Billing and Coding:
   • Oversee the billing and coding processes to ensure accurate and timely submission of claims.
   • Ensure compliance with coding guidelines, payer requirements, and regulatory standards.
   • Collaborate with clinical departments to resolve coding and documentation issues.
4. Claims Management:
   • Manage the claims submission process, including electronic and paper claims.
   • Monitor claim denials and rejections and develop strategies to reduce denial rates.
   • Work with payers to resolve claim issues and ensure timely reimbursement.
5. Collections and Payment Posting:
   • Oversee the collections process to ensure timely and accurate patient payments.
   • Develop and implement policies and procedures for payment posting and reconciliation.
   • Manage patient accounts and resolve billing inquiries and disputes.
6. Compliance and Regulations:
   • Ensure compliance with federal, state, and local regulations, including HIPAA and other healthcare laws.
   • Stay updated on changes in healthcare regulations and payer requirements.
   • Implement and enforce policies and procedures to maintain compliance.
7. Reporting and Analytics:
   • Prepare and present regular reports on revenue cycle performance to senior management.
   • Utilize data analytics to identify trends, issues, and opportunities for improvement.
   • Develop and implement dashboards and other tools to monitor revenue cycle metrics.
8. All Other Duties as Assigned

Qualifications:

• Bachelor’s degree in Healthcare Administration, Business Administration, Finance, or related field. Master’s degree preferred.
• Minimum of 5 years of experience in revenue cycle management, with at least 2 years in a supervisory or managerial role.
• Strong knowledge of healthcare billing, coding, claims processing, and collections.
• Familiarity with healthcare regulations, including HIPAA and payer requirements.
• Proficiency in revenue cycle management software and electronic health record (EHR) systems.
• Excellent leadership, communication, and interpersonal skills.
• Strong analytical and problem-solving abilities.

Ability to work in a fast-paced and dynamic environment.

Key Responsibilities:

1.           Leadership and Team Management:

•             Supervise and mentor a team of Case Management Nurses, providing guidance and support to ensure excellent performance.

•             Foster a collaborative and cohesive work environment within the department.

•             Conduct regular staff meetings, performance evaluations, and staff development activities.

2.           Care Coordination and Oversight:

•             Oversee the development and implementation of individualized care plans for patients.

•             Collaborate with the healthcare team to ensure coordinated and efficient patient care across different healthcare settings.

•             Monitor and assess the appropriateness of care plans and resource utilization.

3.           Quality Improvement:

•             Implement and monitor quality improvement initiatives to enhance patient outcomes and compliance with healthcare regulations.

•             Analyze data and metrics to identify areas for improvement in care coordination processes.

4.           Budget Management:

•             Manage the department's budget and resource allocation efficiently while maintaining high-quality patient care.

•             Collaborate with finance and administrative teams to optimize resource utilization.

5.           Staff Development:

•             Provide ongoing training and education to Case Management Nurses to keep them updated on best practices and regulatory changes.

•             Encourage professional growth and development within the department.

6.           Patient Advocacy:

•             Serve as a patient advocate, ensuring that patients' needs and preferences are addressed throughout their healthcare journey.

•             Participate in complex case reviews and offer guidance on challenging patient cases.

7.           Documentation and Compliance:

•             Ensure accurate and timely documentation of patient records, care plans, and progress notes in accordance with regulatory standards.

Qualifications:

•             Current RN (Registered Nurse) license in [state].

•             Bachelor's degree in Nursing (BSN) preferred.

•             Previous experience in case management or care coordination, with at least [insert number of years] years in a leadership role.

•             Strong clinical assessment and critical thinking skills.

•             Excellent communication and interpersonal skills.

•             Knowledge of healthcare regulations, insurance processes, and quality improvement methodologies.

•             Proficiency in electronic health records (EHR) and healthcare software.

•             Dedication to patient-centered care and a commitment to ethical practice.

If you are an experienced and visionary nurse leader who is passionate about improving patient care and outcomes, we invite you to apply for the Case Management Nurse Manager position. Join our team and lead the way in optimizing patient care. Apply today!

The Coding Auditor will perform detailed reviews of medical documentation and coding, ensuring accuracy, compliance with coding standards, and adherence to regulations such as ICD-10, CPT, and HCPCS. The auditor will work closely with coding teams, providers, and clinical staff to educate on coding practices and provide feedback for continuous improvement.

Key Responsibilities:

• Review and Audit Medical Records: Conduct audits of medical records to ensure that coding is accurate, compliant with payer requirements, and adheres to national coding guidelines (ICD-10, CPT, and HCPCS codes).
• Ensure Regulatory Compliance: Ensure all medical coding aligns with applicable federal, state, and local laws and regulations (including Medicare and Medicaid guidelines).
• Identify Errors and Gaps: Detect and correct coding discrepancies, missing or incomplete documentation, and over- or under-coding issues.
• Provide Feedback and Education: Educate coding staff and healthcare providers on accurate coding practices, documentation improvement, and regulatory changes.
• Prepare Audit Reports: Compile detailed audit reports highlighting findings and corrective actions needed, including recommendations for process improvement.
• Support Revenue Cycle: Work closely with the revenue cycle management team to ensure proper coding for billing and reimbursement.
• Keep Up to Date with Coding Changes: Stay current with updates to coding standards, compliance regulations, and healthcare laws.

Required Skills & Qualifications:

• Certifications: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), or similar certification is required.
• Experience: Minimum of 2-3 years of medical coding or auditing experience and experience with risk adjustment audits, clinical documentation improvement (CDI), and payer audits.
• Knowledge of Coding Systems: Strong knowledge of ICD-10, CPT, and HCPCS coding systems, and familiarity with DRG, E/M coding.
• Bachelor's degree: in Nursing, or any Medical or Health Information Management or a related field.
• Attention to Detail: Exceptional attention to detail with the ability to identify coding and documentation errors.
• Communication Skills: Strong written and verbal communication skills, with the ability to provide feedback to coding teams and clinicians.
• Analytical Skills: Ability to analyze data and develop insights that drive improvements in coding accuracy and compliance.
• Familiarity with Compliance Standards: Knowledge of healthcare compliance standards such as HIPAA, Medicare, and Medicaid regulations.
• Proficiency in Software: Experience using coding and billing software (e.g., Epic, 3M Encoder, Cerner, or other EHR systems).

Clinical Coding Analyst

Health Business Solutions, LLC  Manila (On-site) 

We are seeking a detail-oriented and analytical Clinical Coding Analyst to join our team and take on the responsibility of reviewing claims denied for coding-related issues. As a Clinical Coding Analyst, you will play a critical role in identifying and resolving coding discrepancies, ensuring accurate and compliant coding practices, and optimizing revenue generation. Your expertise in clinical coding, coding guidelines, and claims processing will be instrumental in analyzing and resolving coding-related denials, thereby enhancing operational efficiency and financial performance. 

Company Overview: 

For over 20 years, we’ve been a leading middle market revenue cycle management (RCM) vendor, providing comprehensive financial and operational solutions to health systems, physician groups, or specialty medical practices. Our mission is to improve the overall financial health of our clients by offering customized, data-driven, and tech-enabled recovery of denied claims and aged receivables. We utilize our deep expertise in revenue cycle to help transform our client’s revenue cycle processes to achieve sustained reductions in denial rates. 

Key Responsibilities: 

• Review and analyze claims that have been denied due to coding-related issues, including diagnosis codes (ICD-10-CM), procedure codes (CPT/HCPCS), and related modifiers. 
• Identify coding discrepancies, documentation deficiencies, and other factors contributing to claims denials, utilizing a thorough understanding of coding guidelines, industry standards, and regulatory requirements. 
• Collaborate with coding teams, healthcare providers, and revenue cycle stakeholders to obtain necessary documentation and information for claims resubmission. 
• Conduct in-depth coding audits and analysis to validate the accuracy, completeness, and compliance of coding practices, and ensure alignment with payer requirements. 
• Research and interpret coding guidelines, including updates from coding authorities, to ensure coding accuracy and compliance. 
• Work closely with coding staff and providers to address and resolve coding-related issues, provide education on coding best practices, and improve coding performance. 
• Maintain up-to-date knowledge of payer policies, medical necessity criteria, and reimbursement guidelines to accurately evaluate coding denials and appeals. 
• Compile and prepare detailed reports on coding-related denials, identifying patterns, trends, and opportunities for process improvement. 
• Collaborate with the revenue cycle team to develop strategies and initiatives aimed at reducing coding-related denials and improving overall revenue cycle performance. 
• Stay informed about emerging coding trends, changes in coding guidelines, and industry best practices, and provide recommendations for updating coding processes and policies. 
• Participate in coding-related meetings, committees, and training sessions to share insights, contribute to problem-solving, and promote cross-departmental collaboration. 

Qualifications: 

• Certifications: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), or similar certification is required.
• Experience: Minimum of 2-3 years of medical coding or auditing experience and experience with risk adjustment audits, clinical documentation improvement (CDI), and payer audits.
• Knowledge of Coding Systems: Strong knowledge of ICD-10, CPT, and HCPCS coding systems, and familiarity with DRG, E/M coding.
• Bachelor's degree: in Nursing, or any Medical or Health Information Management or a related field.
• Familiarity with medical necessity criteria, payer policies, and reimbursement methodologies. 
• Excellent understanding of revenue cycle processes, claims processing workflows, and denials management. 
• Proficiency in using coding software, encoders, and electronic health record (EHR) systems. 
• Detail-oriented mindset with a high level of accuracy and organizational skills. 
• Effective communication and interpersonal skills to collaborate with coding teams, providers, and other stakeholders. 
• Ability to work independently, prioritize tasks, and meet deadlines in a fast-paced environment. 
• Proficiency in using coding-related software and tools, as well as a high level of computer literacy. 
• Join our dynamic team as a Clinical Coding Analyst and contribute to the resolution of coding-related denials, ensuring accurate and compliant coding practices that maximize reimbursement and support optimal healthcare delivery. 

 Health Business Solutions, LLC provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. 

Apply for this position

Senior Clinical Coding Analyst - Onsite Manila 

Health Business Solutions, LLC

We are seeking an experienced and detail-oriented Senior Clinical Coding Analyst to join our team and take on a crucial role in ensuring coding quality within our revenue cycle. As a Senior Clinical Coding Analyst, you will be responsible for analyzing and validating clinical codes used in the revenue cycle processes, identifying areas of improvement, and implementing coding quality initiatives. Your expertise in clinical coding, regulatory guidelines, and revenue cycle operations will play a vital role in maintaining accurate and compliant coding practices. 

Company Overview: 

For over 20 years, we’ve been a leading middle market revenue cycle management (RCM) vendor, providing comprehensive financial and operational solutions to health systems, physician groups, or specialty medical practices. Our mission is to improve the overall financial health of our clients by offering customized, data-driven, and tech-enabled recovery of denied claims and aged receivables. We utilize our deep expertise in revenue cycle to help transform our client’s revenue cycle processes to achieve sustained reductions in denial rates. 

Key Responsibilities: 

• Analyze and evaluate clinical codes used in the revenue cycle, including diagnosis codes (ICD-10-CM), procedure codes (CPT/HCPCS), and related modifiers. 
• Conduct regular audits of coded medical records, ensuring accuracy, completeness, and compliance with relevant coding guidelines, industry standards, and regulations. 
• Identify coding discrepancies, documentation deficiencies, and areas for improvement in the coding and revenue cycle processes. 
• Collaborate with coding teams, healthcare providers, and revenue cycle stakeholders to resolve coding-related issues, clarify documentation requirements, and ensure accurate code assignment. 
• Develop and implement coding quality initiatives, including education and training programs, to enhance coding accuracy, compliance, and productivity. 
• Stay up-to-date with the latest changes in coding guidelines, regulations, and industry best practices, and ensure timely implementation of necessary updates within the organization. 
• Provide guidance and mentorship to coding staff, assisting in the resolution of complex coding cases, and promoting professional development. 
• Generate regular reports and metrics related to coding quality, productivity, and compliance, highlighting areas of concern and recommending actionable improvements. 
• Collaborate with IT teams and other stakeholders to optimize coding tools, software, and systems, ensuring seamless integration within the revenue cycle processes. 
• Participate in coding-related projects, committees, and cross-functional teams, representing the coding and revenue cycle perspective and contributing to organizational goals. 

Qualifications: 

• Certifications: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), or similar certification is required.
• Experience: Minimum of 2-3 years of medical coding or auditing experience and experience with risk adjustment audits, clinical documentation improvement (CDI), and payer audits.
• Knowledge of Coding Systems: Strong knowledge of ICD-10, CPT, and HCPCS coding systems, and familiarity with DRG, E/M coding.
• Bachelor's degree: in Nursing, or any Medical or Health Information Management or a related field.
• Proficient in using coding software, encoders, and electronic health record (EHR) systems. 
• Excellent understanding of revenue cycle workflows, including charge capture, billing, claims processing, and reimbursement methodologies. 
• Proven track record in conducting coding audits, implementing coding quality improvement initiatives, and achieving measurable outcomes. 
• Exceptional attention to detail and accuracy, coupled with excellent organizational and problem-solving skills. 
• Effective communication and interpersonal skills, with the ability to collaborate with diverse stakeholders, provide education, and resolve coding-related issues. 
• Ability to work independently, prioritize tasks, and meet deadlines in a dynamic and fast-paced environment. 
• Proficiency in using coding-related software and tools, as well as a high level of computer literacy. 

Join our dynamic organization as a Senior Clinical Coding Analyst, and contribute to the enhancement of coding quality within the revenue cycle, ensuring accurate and compliant coding practices that support optimal healthcare outcomes. 

Health Business Solutions, LLC provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

We are seeking a detail-oriented and analytical Clinical Coding Analyst to join our team and take on the responsibility of reviewing claims denied for coding-related issues. As a Clinical Coding Analyst, you will play a critical role in identifying and resolving coding discrepancies, ensuring accurate and compliant coding practices, and optimizing revenue generation. Your expertise in clinical coding, coding guidelines, and claims processing will be instrumental in analyzing and resolving coding-related denials, thereby enhancing operational efficiency and financial performance. 

Company Overview: 

For over 20 years, we’ve been a leading middle market revenue cycle management (RCM) vendor, providing comprehensive financial and operational solutions to health systems, physician groups, or specialty medical practices. Our mission is to improve the overall financial health of our clients by offering customized, data-driven, and tech-enabled recovery of denied claims and aged receivables. We utilize our deep expertise in revenue cycle to help transform our client’s revenue cycle processes to achieve sustained reductions in denial rates. 

Key Responsibilities: 

• Review and analyze claims that have been denied due to coding-related issues, including diagnosis codes (ICD-10-CM), procedure codes (CPT/HCPCS), and related modifiers. 

• 2 years experience in dealing with relevant revenue cycle operations from a vendor or hospital financial offices, including familiarity with major payors. Preference given to candidates with experience in Florida markets. 
  

• Identify coding discrepancies, documentation deficiencies, and other factors contributing to claims denials, utilizing a thorough understanding of coding guidelines, industry standards, and regulatory requirements. 

• Collaborate with coding teams, healthcare providers, and revenue cycle stakeholders to obtain necessary documentation and information for claims resubmission. 

• Conduct in-depth coding audits and analysis to validate the accuracy, completeness, and compliance of coding practices, and ensure alignment with payer requirements. 

• Research and interpret coding guidelines, including updates from coding authorities, to ensure coding accuracy and compliance. 

• Work closely with coding staff and providers to address and resolve coding-related issues, provide education on coding best practices, and improve coding performance. 

• Maintain up-to-date knowledge of payer policies, medical necessity criteria, and reimbursement guidelines to accurately evaluate coding denials and appeals. 

• Compile and prepare detailed reports on coding-related denials, identifying patterns, trends, and opportunities for process improvement. 

• Collaborate with the revenue cycle team to develop strategies and initiatives aimed at reducing coding-related denials and improving overall revenue cycle performance. 

• Stay informed about emerging coding trends, changes in coding guidelines, and industry best practices, and provide recommendations for updating coding processes and policies. 

• Participate in coding-related meetings, committees, and training sessions to share insights, contribute to problem-solving, and promote cross-departmental collaboration. 

Qualifications: 

• Bachelor's degree in Health Information Management, Health Informatics, or a related field. Relevant certifications (e.g., RHIA, RHIT, CCS). 

• 2 years experience in clinical coding within a healthcare organization, with a focus on claims denial management and coding-related issues. 

• Comprehensive knowledge of coding guidelines, including ICD-10-CM, CPT/HCPCS, and related modifiers, as well as proficiency in applying coding conventions and rules. 

• Familiarity with medical necessity criteria, payer policies, and reimbursement methodologies. 

• Excellent understanding of revenue cycle processes, claims processing workflows, and denials management. 

• Proficiency in using coding software, encoders, and electronic health record (EHR) systems. 

• Detail-oriented mindset with a high level of accuracy and organizational skills. 

• Effective communication and interpersonal skills to collaborate with coding teams, providers, and other stakeholders. 

• Ability to work independently, prioritize tasks, and meet deadlines in a fast-paced environment. 

• Proficiency in using coding-related software and tools, as well as a high level of computer literacy. 

• Join our dynamic team as a Clinical Coding Analyst and contribute to the resolution of coding-related denials, ensuring accurate and compliant coding practices that maximize reimbursement and support optimal healthcare delivery. 

 Health Business Solutions, LLC provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. 

Key Responsibilities:

1.           Leadership and Team Management:

•             Supervise and mentor a team of Case Management Nurses, providing guidance and support to ensure excellent performance.

•             Foster a collaborative and cohesive work environment within the department.

•             Conduct regular staff meetings, performance evaluations, and staff development activities.

2.           Care Coordination and Oversight:

•             Oversee the development and implementation of individualized care plans for patients.

•             Collaborate with the healthcare team to ensure coordinated and efficient patient care across different healthcare settings.

•             Monitor and assess the appropriateness of care plans and resource utilization.

3.           Quality Improvement:

•             Implement and monitor quality improvement initiatives to enhance patient outcomes and compliance with healthcare regulations.

•             Analyze data and metrics to identify areas for improvement in care coordination processes.

4.           Budget Management:

•             Manage the department's budget and resource allocation efficiently while maintaining high-quality patient care.

•             Collaborate with finance and administrative teams to optimize resource utilization.

5.           Staff Development:

•             Provide ongoing training and education to Case Management Nurses to keep them updated on best practices and regulatory changes.

•             Encourage professional growth and development within the department.

6.           Patient Advocacy:

•             Serve as a patient advocate, ensuring that patients' needs and preferences are addressed throughout their healthcare journey.

•             Participate in complex case reviews and offer guidance on challenging patient cases.

7.           Documentation and Compliance:

•             Ensure accurate and timely documentation of patient records, care plans, and progress notes in accordance with regulatory standards.

Qualifications:

•             Current RN (Registered Nurse) license in [state].

•             Bachelor's degree in Nursing (BSN) preferred.

•             Previous experience in case management or care coordination, with at least [insert number of years] years in a leadership role.

•             Strong clinical assessment and critical thinking skills.

•             Excellent communication and interpersonal skills.

•             Knowledge of healthcare regulations, insurance processes, and quality improvement methodologies.

•             Proficiency in electronic health records (EHR) and healthcare software.

•             Dedication to patient-centered care and a commitment to ethical practice.

If you are an experienced and visionary nurse leader who is passionate about improving patient care and outcomes, we invite you to apply for the Case Management Nurse Manager position. Join our team and lead the way in optimizing patient care. Apply today!

The Revenue Cycle Operations Director will oversee all aspects of the revenue cycle, from billing and coding to claims processing and collections. This role will be responsible for ensuring the efficiency, accuracy, and financial integrity of revenue cycle processes, driving improvement initiatives, and ensuring compliance with industry regulations. The Director will collaborate with key departments such as business intelligence, sales, and operations to optimize revenue cycle functions and align with the overall company strategy.

Key Responsibilities:

Leadership and Strategy:

• • Lead, manage, and mentor the revenue cycle management team, ensuring a high level of engagement and productivity.
  • Develop and implement strategies to improve revenue cycle processes, reduce denials, and enhance revenue capture.
  • Analyze revenue cycle trends, including key performance indicators (KPIs), to develop improvement strategies that align with company goals.

Revenue Cycle Management:

• Oversee all functions of the revenue cycle, including patient registration, coding, billing, claims processing, payment posting, denial management, and collections.
• Collaborate with departments such as operations, business intelligence, and sales to improve workflows and achieve revenue optimization.
• Develop and maintain policies and procedures related to revenue cycle activities, ensuring compliance with healthcare regulations and payer requirements.
• Ensure timely and accurate submission of claims and the effective management of accounts receivable to maintain optimal cash flow.

Team Collaboration:

• Work closely with the operations and business intelligence teams to create streamlined workflows and reduce operational inefficiencies.
• Coordinate with the sales and growth department to identify new opportunities and ensure revenue cycle readiness for expanded service lines or contracts.

Process Improvement and Optimization:

• Identify and implement revenue cycle improvements, using data-driven analysis to reduce claim denials, shorten revenue cycle time, and enhance payment collections.
• Introduce automation or technological solutions where possible to improve efficiency in revenue cycle processes.
• Monitor regulatory changes that impact revenue cycle operations and ensure compliance with federal, state, and payer guidelines.

Financial Oversight:

• Work closely with finance and executive leadership to create revenue cycle financial reports and contribute to strategic planning.
• Manage and monitor the departmental budget, making adjustments as necessary to optimize resource allocation and performance.

Compliance and Reporting:

• Ensure adherence to all federal, state, and local laws and regulations related to billing, coding, and collections.
• Prepare and present regular reports on revenue cycle performance, including KPIs, for executive leadership.
• Conduct audits to ensure the accuracy and integrity of revenue cycle operations.

Qualifications:

• Bachelor’s degree in Business Administration, Healthcare Management, Finance, or a related field (Master’s preferred).
• 7+ years of experience in revenue cycle management, with at least 3 years in a leadership role.
• Strong understanding of healthcare billing and coding, payer regulations, and revenue cycle processes.
• Proven experience in developing and implementing process improvements.
• Excellent analytical, problem-solving, and decision-making skills.
• Ability to work collaboratively with cross-functional teams and executive leadership.
• Strong organizational and leadership abilities, with experience managing large teams.
• Excellent communication and presentation skills.

Preferred Skills:

• Familiarity with revenue cycle management software and tools (e.g., Epic, Cerner, Athenahealth).
• Knowledge of healthcare revenue cycle KPIs and best practices for improving metrics like Days in Accounts Receivable (AR), denial rates, and collections.

Health Business Solutions (HBiz) is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all employees and applicants without regard to race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability, genetic information, veteran status, or any other status protected by applicable federal, state, or local law.

HBiz complies with all applicable employment laws for remote and multi-state hiring and provides reasonable accommodations as required by law.

Location: Philippines

About Us:

HBiz is a leading Revenue Cycle Management (RCM) company dedicated to helping healthcare providers optimize their financial performance. We specialize in delivering innovative solutions that streamline revenue cycle operations and enhance overall revenue generation for healthcare organizations. Our mission is to empower healthcare providers with the tools and expertise needed to maximize revenue, reduce operational costs, and improve patient care.

Job Summary:

We are seeking a highly motivated and experienced Clinical Case Management Nurse to join our team. The Clinical Case Management Nurse will play a crucial role in supporting our clients in the healthcare industry by providing expert clinical guidance, facilitating effective case management, and ensuring revenue cycle efficiency. This position offers a unique opportunity to combine clinical expertise with revenue cycle management knowledge.

Key Responsibilities:

Clinical Assessment: Conduct comprehensive clinical assessments to determine the patient's medical condition, healthcare needs, and treatment options.

Patient Advocacy: Serve as an advocate for patients by ensuring they receive appropriate care, coordinating with healthcare providers, and assisting in the resolution of healthcare-related issues.

Care Coordination: Collaborate with interdisciplinary healthcare teams to coordinate patient care and treatment plans, ensuring the most cost-effective and clinically appropriate care is provided.

Revenue Cycle Management: Utilize clinical expertise to support revenue cycle processes, including accurate coding, documentation improvement, and compliance with healthcare regulations.

Utilization Review: Evaluate the necessity and appropriateness of healthcare services and assist in the management of length of stay, ensuring that healthcare resources are used efficiently.

Documentation Improvement: Identify opportunities for improving clinical documentation to support accurate coding and billing processes, ultimately improving reimbursement.

Patient Education: Educate patients and their families about healthcare options, treatment plans, and financial responsibilities, helping to promote informed decision-making.

Quality Assurance: Ensure the quality of care provided meets or exceeds established standards and that clinical documentation accurately reflects the patient's condition and care provided.

Data Analysis: Analyze clinical and financial data to identify trends, opportunities for improvement, and areas of potential cost savings for clients.

Compliance: Stay up-to-date with healthcare regulations, guidelines, and policies to ensure all patient care and revenue cycle processes are in compliance with industry standards.

Qualifications:

Registered Nurse (RN) licensure in the state of practice.

Bachelor of Science in Nursing (BSN) preferred.

Case Management Certification (e.g., CCM) is a plus.

Minimum of 2 years of clinical nursing experience, preferably in a hospital or acute care setting.

Strong understanding of revenue cycle management and healthcare reimbursement.

Proficiency in medical coding and clinical documentation improvement.

Excellent communication, interpersonal, and teamwork skills.

Ability to work independently and make sound clinical and financial decisions.

Strong analytical and problem-solving skills.

Proficient in using healthcare information systems and technology.

Commitment to maintaining patient confidentiality and ethical standards.

Benefits:

Competitive salary

Comprehensive healthcare benefits

Professional development and training opportunities

Collaborative and supportive work environment

Opportunities for advancement within the company

Work-life balance programs

If you are a skilled Clinical Case Management Nurse who is passionate about enhancing patient care and optimizing revenue cycle processes, we encourage you to apply for this exciting opportunity with [Company Name]. Join us in making a positive impact on the healthcare industry and helping healthcare providers thrive financially while providing top-notch patient care.

**** Salaries from 60,000 to 90,000 PhP per month depending on experience******

Key Responsibilities:

1. Review and analyze clinical documentation, utilization records, and insurance denial rationales to formulate well-constructed appeal cases.
2. Engage in the appeals process for denied claims, ensuring that all appeals are submitted in a timely manner according to regulatory and insurer-specific requirements.
3. Utilize clinical experience and knowledge in accordance with established Milliman or Interqual guidelines to substantiate medical necessity and appropriate level of care.
4. Collaborate with healthcare providers, case managers, and insurance companies to gather additional information and advocate for proper patient services and reimbursement.
5. Interpret and apply ICD-10 coding in the review of medical records to support appeal submissions.
6. Maintain accurate and detailed records of all appeals processes, outcomes, and communications.
7. Educate clinical staff on best practices, changes in payer requirements, and implications of clinical documentation and coding standards.
8. Stay abreast of changes in healthcare regulations, payer policies, and clinical criteria guiding medical necessity.

Required Qualifications:

• Active Registered Nurse (RN) license in the Philippines, US licensed preferred
• Minimum of two years of bedside clinical experience in a hospital setting.
• At least one year of experience in clinical appeals or utilization management.
• Bachelor’s Degree in Nursing (BSN) preferred; minimum of an Associate Degree in Nursing (ADN) required.
• Proficiency with Milliman or Interqual clinical guidelines.
• Strong understanding of ICD-10 coding principles.
• Excellent written communication skills, with the ability to articulate complex clinical information in a clear and professional manner for appeal justifications.
• Strong organizational skills and the ability to manage multiple cases simultaneously.

Desired Skills:

• Exceptional critical thinking and problem-solving skills.
• Demonstrated ability to work independently as well as part of a team.
• Commitment to ethical medical practices and compliance with all federal and state regulations.

What We Offer:

• Competitive salary and benefits package including health and paid time off.
• Opportunities for professional growth and continuing education.
• Supportive work environment focused on teamwork and positive outcomes.
• HBiz is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
• We look forward to considering your application and hopefully welcoming you to our team!

We are seeking a detail-oriented and experienced Insurance Denials Management Specialist to join our team, specializing in hospice claims. The ideal candidate will have a strong background in analyzing, appealing, and resolving insurance denials to optimize reimbursement and ensure compliance with hospice care billing regulations.

Key Responsibilities:

• Review, analyze, and manage insurance claim denials specifically related to hospice care services.
• Identify root causes of claim denials and develop effective strategies for appeal and resolution.
• Prepare and submit timely and accurate appeals to insurance payers, including Medicare, Medicaid, and private insurers.
• Collaborate closely with billing, clinical, and coding teams to ensure accurate documentation and coding compliance for hospice claims.
• Monitor denial trends and report findings to management to improve revenue cycle processes.
• Maintain up-to-date knowledge of hospice billing regulations, payer policies, and industry best practices.
• Track and document all denial management activities in the appropriate systems.
• Communicate effectively with insurance companies, internal departments, and external providers to expedite claim resolutions.
• Assist in training staff on hospice-specific denials management processes and requirements.
• Contribute to process improvement initiatives to reduce denial rates and accelerate payment cycles.

Qualifications:

• Minimum of 2 years experience in insurance denials management with a focus on hospice claims.
• In-depth understanding of hospice billing, coding (including ICD-10, CPT, and HCPCS), and regulatory requirements.
• Familiarity with Medicare Hospice Benefit and payer-specific policies.
• Strong analytical and problem-solving skills.
• Excellent written and verbal communication skills.
• Proficient in denial management software, billing systems, and MS Office applications.
• Ability to work independently and as part of a team in a fast-paced environment.
• Detail-oriented with strong organizational skills.

Preferred:

• Certification in Medical Billing, Coding, or Revenue Cycle Management (e.g., CPC, CPB) a plus.
• Experience working with electronic health record (EHR) systems and hospice-specific billing platforms.
• Knowledge of compliance and audit requirements related to hospice care claims.

HBiz is seeking an experienced and highly organized Manager of Audit to lead all audit-related operations across government, commercial, and post-payment audits. This fully remote role will report directly to the VP of Clinical Appeals and is responsible for overseeing end-to-end audit processes, ensuring regulatory compliance, and managing a team that includes offshore staff. The ideal candidate is a strong communicator, detail-oriented, and comfortable working flexible hours to support coordination across global teams and time zones.

Key Responsibilities:

• Audit Oversight & Lifecycle Management
  • Lead the management and response process for a variety of audits including RAC, MAC, CERT, PERM, TPE, and commercial payer audits.
  • Oversee case intake, documentation collection, quality review, and timely submission.
  • Track and analyze audit trends, denials, and appeal outcomes to identify risks and recommend improvements.
• Reporting & Tracking
  • Maintain detailed audit logs and status reports using audit tracking systems.
  • Develop and deliver regular audit performance dashboards and summaries to leadership.
  • Identify audit trends and provide insights for proactive risk mitigation.
• Team Management & Workflow Coordination
  • Supervise and support a team of audit staff, including managing offshore resources.
  • Assign and coordinate cases with clinical, coding, technical, and documentation teams.
  • Ensure efficient workflows and balanced workloads across team members.
  • Work flexible hours when needed to support offshore operations and tight deadlines.
• Collaboration Across Departments
  • Act as the liaison between clinical, coding, HIM, compliance, and IT teams for audit support.
  • Ensure audit responses include accurate, complete, and compliant documentation.
  • Facilitate escalation and resolution of complex audit issues.
• Compliance & Quality Assurance
  • Ensure all audit activity complies with CMS, commercial payer, and regulatory requirements.
  • Support policy and process development to strengthen audit readiness and response.
  • Participate in internal audits and risk assessments as needed.

Qualifications:

• Bachelor’s degree in Health Information Management, Healthcare Administration, Business, or related field (Master’s preferred).
• Minimum 5 years of healthcare audit experience, including government and post-payment audits.
• At least 2 years in a supervisory or leadership role, including managing remote/offshore staff.
• In-depth understanding of audit regulations, payer requirements, and healthcare reimbursement.
• Familiarity with medical coding (ICD-10, CPT, HCPCS), billing practices, and clinical documentation standards.
• Excellent communication, organizational, and leadership skills.
• Proficient with audit tracking software, EHRs, and Microsoft Office Suite.

The ideal candidate is articulate, organized, detail-oriented, and able to adjust their schedule as needed to engage with teams across a global network and multiple time zones.

Acts as a liaison between internal Hbiz clients, (i.e.: coding, HIM, compliance, and IT teams); as well as external clients we are supporting with our services.

Job Summary:

We are seeking a detail-oriented and driven Post-Pay Audit Manager to lead a team of auditors performing retrospective audits across commercial and government payers. Reporting directly to the Director of Post-Pay Audit, this role is responsible for daily operations management, performance oversight, and quality assurance across onshore and offshore teams, including staff based in the Philippines.

The ideal candidate has experience in medical claims auditing, strong leadership capabilities, and a solid understanding of Medicare, Medicaid, and other payer reimbursement requirements. This position plays a key role in maximizing revenue recovery while ensuring compliance and process excellence.

Key Responsibilities:

• Supervise daily audit operations across onshore and offshore teams, ensuring accuracy, productivity, and timely completion of audit deliverables.
• Provide hands-on leadership, training, and mentorship to audit staff, fostering a high-performance and quality-focused team culture.
• Monitor performance metrics, individual KPIs, and quality assurance results to drive continuous improvement.
• Coordinate the execution of audits for government (RAC, UPIC, MAC) and commercial payers, ensuring adherence to payer policies and audit guidelines.
• Collaborate with the Director of Post-Pay Audit on staffing, planning, and workflow optimization across multiple time zones.
• Conduct regular audit reviews, spot checks, and root cause analysis to ensure compliance and identify patterns of underpayment or denial.
• Escalate complex audit findings or payer discrepancies to senior leadership as needed.
• Assist in the development and implementation of standard operating procedures (SOPs) and training documentation.
• Support audit readiness and documentation for internal and external quality audits.
• Foster strong communication between onshore and offshore teams to ensure alignment on goals and expectations.

Qualifications:

• Bachelor’s degree in Healthcare Administration, Health Information Management, Business, or related field required.
• Minimum of 5 years of experience in medical auditing, revenue cycle management, or claims recovery.
• At least 2 years in a supervisory or team lead role, preferably with remote or offshore team management experience.
• Solid knowledge of government audit programs (RAC, MAC, Medicaid Integrity, UPIC) and commercial payer policies.
• Proficiency in healthcare billing, medical coding (ICD-10, CPT, HCPCS), and EOB analysis.
• Strong analytical, organizational, and decision-making skills.
• Experience using audit/recovery software platforms and workflow tools.
• Professional certification preferred (e.g., CPMA, CPC, RHIA, CHC).
• Ability to work cross-functionally in a dynamic, deadline-driven environment.

We are seeking a highly experienced and strategic Director of Post-Pay Audit to lead our medical revenue recovery audit teams across both onshore (U.S.) and offshore (Philippines) operations. This leader will be responsible for overseeing the execution of comprehensive post-payment audits across commercial and government payers (Medicare, Medicaid, TRICARE, etc.), ensuring compliance, accuracy, and maximum revenue recovery for healthcare provider clients.

The ideal candidate brings deep knowledge of healthcare reimbursement policies, government audit programs (e.g., RAC, UPIC, MAC), and a proven ability to lead cross-functional and cross-cultural teams at scale.

Key Responsibilities:

• Lead and manage the end-to-end post-pay audit function, including planning, execution, quality assurance, and reporting.
• Direct and support a global team of audit professionals, ensuring productivity, accuracy, and compliance across both U.S.-based and Philippines-based operations.
• Oversee audit processes related to government payers and regulatory programs (e.g., CMS RAC, Medicaid Integrity Program, etc.).
• Establish and refine audit workflows, KPIs, and escalation protocols to optimize audit yield and recovery timelines.
• Collaborate with compliance, legal, and analytics teams to identify audit opportunities and mitigate risk.
• Serve as the subject matter expert for payer audit guidelines, CMS regulations, and state-specific requirements.
• Build strong relationships with internal stakeholders and clients to align audit strategies with broader revenue recovery goals.
• Develop and execute training programs and professional development plans for onshore and offshore audit staff.
• Ensure adherence to internal quality standards, HIPAA regulations, and client-specific SLAs.
• Analyze audit outcomes and present regular performance and risk reports to senior leadership.

Qualifications:

• Bachelor’s degree in Healthcare Administration, Business, Finance, or related field required; Master’s or MBA preferred
• Minimum of 7–10 years of experience in post-payment auditing, healthcare reimbursement, or revenue recovery
• Proven experience managing global teams, including operations based in the Philippines
• Strong knowledge of government audit programs (RAC, MAC, CERT, ZPIC/UPIC, Medicaid audits)
• Excellent understanding of healthcare billing, coding (ICD-10, CPT, HCPCS), and payer policies
• Demonstrated ability to lead process improvement initiatives in large-scale audit operations
• High proficiency with audit and recovery systems, reporting tools, and workflow platforms
• Strong communication, leadership, and analytical skills
• Certification in auditing, billing, or compliance (e.g., CPMA, CPC, CHC) is a plus

Health Business Solutions (HBiz) is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all employees and applicants without regard to race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability, genetic information, veteran status, or any other status protected by applicable federal, state, or local law.

HBiz complies with all applicable employment laws for remote and multi-state hiring and provides reasonable accommodations as required by law.

We are seeking an experienced and highly organized Manager of Clinical Appeals to lead our clinical appeals operations across commercial and government payers. This role is responsible for overseeing day-to-day activities of clinical appeal specialists, managing appeal strategy execution, ensuring quality and compliance, and meeting client-specific performance goals.

The ideal candidate brings a strong background in clinical review, medical necessity denials, payer appeal processes, and team leadership—ideally across both U.S. and offshore teams (e.g., Philippines). This position is critical to ensuring timely and effective resolution of denied claims, supporting revenue recovery efforts, and maintaining payer and regulatory compliance.

Key Responsibilities:

• Manage the full-cycle clinical appeals process across multiple payer types, with a focus on government (e.g., Medicare, Medicaid) and commercial payers.
• Lead and support a team of nurses, clinical reviewers, and appeal specialists—including potential offshore (Philippines-based) staff.
• Monitor appeal workloads, productivity, and turnaround times to ensure all appeal deadlines and client service level agreements (SLAs) are met.
• Review and approve complex or high-value clinical appeal cases, ensuring clinical accuracy and compliance with payer guidelines.
• Maintain up-to-date knowledge of medical necessity criteria, payer policies, NCDs/LCDs, and applicable CMS regulations.
• Train new and existing team members on clinical guidelines, appeal writing standards, and regulatory requirements.
• Work cross-functionally with audit, legal, compliance, and operations teams to align on strategy and escalate trends or systemic payer issues.
• Identify and implement process improvements to increase efficiency, reduce denials, and improve overturn rates.
• Support the creation and refinement of appeal templates, clinical arguments, and documentation standards.
• Generate and deliver performance and quality reports to leadership, identifying risks and opportunities for improvement.

Qualifications:

• Registered Nurse (RN) or clinical degree required; Bachelor's degree in Nursing, Health Administration, or related field preferred.
• 5+ years of experience in clinical appeals, utilization review, or medical necessity denials.
• 2+ years in a leadership or supervisory role, preferably within a revenue cycle or payer appeals setting.
• In-depth understanding of payer denial processes, especially Medicare Advantage, Medicaid Managed Care, and commercial plans.
• Experience managing remote and/or offshore teams (Philippines experience preferred).
• Strong working knowledge of ICD-10, CPT, and HCPCS coding as they relate to clinical justifications.
• Excellent writing skills and the ability to clearly communicate complex clinical reasoning.
• Familiarity with appeal submission portals, EHRs, and workflow platforms.
• Knowledge of HIPAA, CMS, and NCQA standards.

The Claims Analyst – Professional Billing (PB) is responsible for analyzing, auditing, and resolving claims related to professional (physician and ancillary) services to ensure accurate billing, coding, and reimbursement. This position plays a key role in supporting the revenue cycle by reviewing claim accuracy, identifying trends or discrepancies, and ensuring compliance with payer contracts, coding guidelines, and regulatory standards. The analyst collaborates with providers, coders, billing teams, and payers to optimize claim performance and minimize denials or payment delays.

Key Responsibilities 

Review and analyze professional billing claims for accuracy, completeness, and compliance with payer policies and coding standards (CPT, HCPCS, ICD-10).

Identify, research, and resolve claim rejections, denials, and underpayments through detailed root cause analysis.

Perform claim audits to ensure billing integrity and adherence to payer contracts and CMS regulations.

Partner with coding and billing teams to correct claim errors and submit timely appeals or resubmissions.

Monitor claim trends, payment variances, and denial rates; provide actionable insights and recommendations for process improvements.

Interpret payer fee schedules, EOBs, and remittance advices to validate payment accuracy.

Support configuration and maintenance of claim processing rules in billing systems (e.g., Epic PB, Cerner, or other practice management systems).

Prepare reports and dashboards tracking key performance metrics, such as clean claim rates, denial rates, and reimbursement accuracy.

Collaborate cross-functionally with revenue integrity, compliance, and finance to ensure alignment of billing practices with internal policies and external regulations.

Stay current on industry changes, including payer updates, coding revisions, and regulatory requirements (e.g., CMS, HIPAA, OIG).

Qualifications:

Education & Experience:

Bachelor’s degree in healthcare administration, business, finance, or related field preferred.

2+ years of experience in professional billing, claims analysis, or healthcare revenue cycle management required.

Strong understanding of CPT, HCPCS, ICD-10 coding, and payer billing requirements.

Experience with billing and EHR systems (e.g., Epic Professional Billing, Cerner, Athena, or equivalent) strongly preferred.

Familiarity with payer contracts, remittance processing, and reimbursement methodologies (FFS, capitation, value-based).

Skills & Competencies:

Excellent analytical and problem-solving skills with strong attention to detail.

Proficient in Microsoft Excel and data analysis/reporting tools; experience with SQL or BI tools is a plus.

Strong understanding of healthcare billing workflows, payer rules, and compliance standards.

Effective written and verbal communication skills with ability to collaborate across departments.

Ability to manage multiple tasks and meet deadlines in a fast-paced environment.

Key Performance Indicators (KPIs)

Clean claim rate

Denial and rework rate

Average days to resolve claim issues

Payment variance accuracy

Timeliness and accuracy of audits and reports

We are seeking a detail-oriented, knowledgeable, and proactive Clinical Quality Auditor to help ensure the integrity and quality of our clinical appeals. As an internal team member, you'll have the advantage of already being familiar with our processes and culture, making you an ideal candidate for this role. In this position, you will audit clinical appeals to ensure compliance with established guidelines, best practices, and internal quality metrics.

Key Responsibilities:

• Conduct audits of clinical appeals to ensure the use of correct appeal letter structure, adherence to the provided guidance/ medical records documentation, and consistency with payor policies and guidelines.
• Utilize all available tools, including Atlas, Epic, Cleopatra, MCG, and email correspondence to ensure the data in our completed appeals is accurate and compliant with established healthcare guidelines.
• Stay abreast of new guidance relevant to the structure of appeals and collaborate with relevant personnel to ensure the team is made aware of any such changes in a timely manner.
• Identify areas of improvement and non-compliance, providing detailed feedback and corrective action plans to relevant team-leads/team members as needed.
• Collaborate with Clinical Quality Manager and Director of Clinical Appeals to identify areas of opportunity and provide feedback to continuously improve and streamline our QA process.
• Maintain and update audit findings, tracking the resolution of issues and documenting corrective actions.
• Prepare audit reports, providing clear and concise documentation regarding relevant findings, trends, and recommendations for continuous improvement.
• Participate in team meetings and training sessions to stay updated on regulatory changes and quality assurance best practices.
• Support peer education and contribute to training sessions focused on audit findings, quality standards, and process improvements.

Key Qualifications:

• Active employment at Hbiz Solutions as a Clinical Appeals Specialist for at least 1 year (internal applicants only)
• Bachelor’s of Science in Nursing (or equivalent degree/certification)
• Three (3) years work experience as a Registered Nurse in a hospital or equivalent clinical setting
• Experience in clinical operations, clinical research, or healthcare-related fields
• Strong understanding of clinical trial protocols, Good Clinical Practice (GCP), and healthcare regulatory requirements (e.g., FDA, HIPAA, etc.)
• Demonstration of leadership skills in current role
• Detail-oriented with strong organizational, communication and analytical skills
• Excellent written and verbal communication skills, with the ability to present audit findings and collaborate with cross-functional teams
• Proficiency with audit tracking tools (Qodex) and Microsoft tools (Word, Excel, PowerPoint) for data review and visualization
• Ability to work independently and as part of a team in a fast-paced environment
• Strong problem-solving skills and the ability to prioritize tasks effectively
• Referral/Recommendation from a Team Lead/Operations Manager
• Currently in good standing in current position (i.e meeting highest quality and productivity goals)

Why Apply for This Internal Opportunity?

• Career Development: Transition into a specialized role and expand your knowledge and expertise in clinical quality assurance.
• Collaborative Environment: Work with highly skilled colleagues and contribute to improving existing company outcome to facilitate further company growth and operational excellence.
• Competitive Compensation: Enjoy a competitive salary and benefits package, with opportunities for career growth within the organization.
• Internal Mobility: Leverage your existing knowledge of company culture, processes, and systems to succeed in this new role.

How to Apply:

If you are a current HBiz employee and are interested in this opportunity, please submit your updated resume and a brief cover letter outlining your interest in the position to the Clinical Quality Manager and Director of Clinical Operations. Please note your referring Team Lead and/Operations Manager and ensure they are copied on your email application. Applications will be reviewed by the Clinical Quality Assurance team, and candidates will be contacted for interviews based on suitability.

We encourage all internal candidates recommended by a Team Lead to apply and look forward to seeing how you can contribute to maintaining and improving the quality of our clinical appeals!

• Review denied medical claims to determine reasons for denial (coding errors, missing information, medical necessity, eligibility, etc.).
• Collect, organize, and verify supporting documentation needed for appeals or audits.
• Prepare and submit claim audit packets for internal review or external payor reconsideration.
• Collaborate with clinical staff, coders, and billing teams to resolve discrepancies and correct claim data.
• Maintain accurate tracking of denied claims, appeals filed, and outcomes for reporting purposes.
• Identify trends in denials and escalate recurring issues to management for process improvement.
• Ensure compliance with HIPAA, CMS, and payor guidelines.
• Assist with internal audits, quality checks, and special projects as assigned.

Qualifications

• Bachelor's degree in healthcare administration, business, or related field preferred.
• Minimum of 3 years prior experience in medical claims, billing, coding, or auditing highly desirable.
• Knowledge of ICD-10, CPT, and HCPCS coding, as well as medical terminology.
• Familiarity with payor policies, EOBs, and claim adjudication processes.
• Strong organizational skills with attention to detail and accuracy.
• Ability to work with confidential patient and claims information in compliance with HIPAA.
• Proficiency in Microsoft Office Suite and experience with claims management systems (Epic, Facets, Availity, etc. preferred).

Skills & Competencies

• Analytical thinking and problem-solving
• Strong written and verbal communication
• Time management and multitasking
• Collaboration and teamwork
• Process improvement mindset

Review denied medical claims to determine reasons for denial (coding errors, missing information, medical necessity, eligibility, etc.).

Collect, organize, and verify supporting documentation needed for appeals or audit

Prepare and submit claim audit packets for internal review or external payor reconsideration.
Collaborate with clinical staff, coders, and billing teams to resolve discrepancies and correct claim data.
Maintain accurate tracking of denied claims, appeals filed, and outcomes for reporting purposes.
Identify trends in denials and escalate recurring issues to management for process improvement.
Ensure compliance with HIPAA, CMS, and payor guidelines.
Assist with internal audits, quality checks, and special projects as assigned.

Qualifications
Bachelor's degree in healthcare administration, business, or related field preferred.
Minimum of 3 years prior experience in medical claims, billing, coding, or auditing highly desirable.Knowledge of ICD-10, CPT, and HCPCS coding, as well as medical terminology.Familiarity with payor policies, EOBs, and claim adjudication processes.
Strong organizational skills with attention to detail and accuracy.Ability to work with confidential patient and claims information in compliance with HIPAA.
Proficiency in Microsoft Office Suite and experience with claims management systems (Epic, Facets, Availity, etc. preferred).

Skills & Competencies
Analytical thinking and problem-solvingStrong written and verbal communication
Time management and multitasking
Collaboration and teamwork
Process improvement mindset

The ideal candidate has prior experience supporting mid- to senior-level hospital executives in a healthcare environment, possesses a working understanding of U.S. hospital administrative and reimbursement structures, and has demonstrated success working within offshore or BPO-supported operating models. This role requires exceptional organization, discretion, technical fluency, and the ability to operate independently in a fast-paced, highly regulated healthcare environment.

Education and Experience

• Bachelor's degree in Healthcare Administration, Business Administration, Health Information Management, or a related field preferred; equivalent experience may be considered.
• 5+ years of executive administrative support experience in a healthcare setting, with direct support of mid- to senior-level hospital or health system leaders strongly preferred.
• Demonstrated experience supporting executives who oversee offshore or remote operational teams, including coordination across time zones and cultures.
• Prior exposure to U.S. hospital operations, revenue cycle, utilization management, case management, or financial services environments required.
• Experience managing multiple client environments, including separate email accounts, calendars, software platforms, and access credentials.
• Familiarity with hospital EMR, billing, or revenue cycle systems (e.g., Epic, Cerner, Meditech, or comparable platforms).
• Bonus if candidate possesses experience in healthcare BPO organizations, offshore service delivery models, or payer/provider administrative operations.
• Strong proficiency with Microsoft Suite (Word, PowerPoint, Excel), Teams, SharePoint, and document management tools in multi-tenant environments.

Knowledge

• Working knowledge of U.S. hospital administrative structures, including clinical, financial, and operational leadership hierarchies.

• Foundational understanding of the U.S. insurance reimbursement system, including Medicare, Medicaid, and commercial payer constructs.
• Knowledge of healthcare compliance considerations, including HIPAA, data access controls, and information security standards.
• Understanding of offshore outsourcing models, including role delineation, service-level expectations, and operational governance.
• Awareness of revenue cycle and utilization-related workflows sufficient to anticipate executive support needs and operational dependencies.
• Exceptional organizational and time-management skills to manage high volumes of competing priorities across multiple clients and platforms.
• Strong written and verbal communication skills with the ability to interface professionally with hospital executives, physicians, offshore leaders, and internal teams.
• Technical aptitude to manage user access, permissions, and navigation across EMR, billing, and client-specific operational software platforms.
• High level of discretion, judgment, and professionalism when handling sensitive clinical, financial, and personnel-related information.
• Ability to work independently in a remote environment, anticipate executive needs, and proactively resolve issues before escalation.
• Cross-cultural collaboration skills to effectively support offshore teams and facilitate seamless executive communication.
• Problem-solving skills to navigate ambiguity, shifting priorities, and complex operational environments with minimal direction.
• Provide comprehensive executive administrative support to the Senior Director or higher, including complex scheduling, meeting coordination, and priority management across multiple clients.
• Manage multiple Outlook email accounts and calendars, including client-specific inboxes, executive correspondence, and coordination across internal and external stakeholders.
• Serve as the primary administrative liaison between the executive, U.S.-based hospital clients, and offshore operational teams.
• Coordinate and maintain access to multiple client-specific software platforms, including EMRs, billing systems, operational tools, and secure portals.
• Track and manage user accounts, permissions, onboarding, and offboarding activities for executive-facing client systems in collaboration with IT and client contacts.
• Prepare, organize, and distribute executive materials including agendas, presentations, reports, meeting minutes, and operational documentation.
• Facilitate recurring operational, client, and leadership meetings, including scheduling across time zones, agenda preparation, and follow-up action tracking.
• Support communication workflows related to offshore operations, including documentation routing, issue tracking, and executive-level escalations.
• Maintain accurate records, files, and documentation in compliance with client, corporate, and regulatory requirements.
• Anticipate executive needs related to client deliverables, operational milestones, and stakeholder communications, proactively addressing gaps or risks.
• Assist with coordination of client onboarding, contract-related administrative tasks, and operational readiness activities.
• Support ad hoc projects related to revenue cycle operations, outsourcing governance, and executive initiatives as assigned.
• Ensure consistent, professional representation of the organization in all executive communications with clients, partners, and internal teams.

Skills

• Advanced executive-level calendar and inbox management across multiple Outlook accounts, including prioritization, delegation, and proactive conflict resolution.

Work Context

This role supports a fully remote executive overseeing U.S. hospital clients and offshore operational teams, requiring flexibility across time zones and nontraditional work hours as needed.

The position operates in a highly regulated healthcare environment and requires strict adherence to confidentiality, security, and compliance standards.

Daily work involves frequent interaction with hospital leadership, offshore operations teams, and internal corporate stakeholders across multiple client engagements.

Primary Job Duties

The essential functions include, but are not limited to the following:

• Provide comprehensive executive administrative support to the Senior Director or higher, including complex scheduling, meeting coordination, and priority management across multiple clients.
• Manage multiple Outlook email accounts and calendars, including client-specific inboxes, executive correspondence, and coordination across internal and external stakeholders.
• Serve as the primary administrative liaison between the executive, U.S.-based hospital clients, and offshore operational teams.
• Coordinate and maintain access to multiple client-specific software platforms, including EMRs, billing systems, operational tools, and secure portals.
• Track and manage user accounts, permissions, onboarding, and offboarding activities for executive-facing client systems in collaboration with IT and client contacts.
• Prepare, organize, and distribute executive materials including agendas, presentations, reports, meeting minutes, and operational documentation.
• Facilitate recurring operational, client, and leadership meetings, including scheduling across time zones, agenda preparation, and follow-up action tracking.
• Support communication workflows related to offshore operations, including documentation routing, issue tracking, and executive-level escalations.
• Maintain accurate records, files, and documentation in compliance with client, corporate, and regulatory requirements.
• Anticipate executive needs related to client deliverables, operational milestones, and stakeholder communications, proactively addressing gaps or risks.
• Assist with coordination of client onboarding, contract-related administrative tasks, and operational readiness activities.
• Support ad hoc projects related to revenue cycle operations, outsourcing governance, and executive initiatives as assigned.
• Ensure consistent, professional representation of the organization in all executive communications with clients, partners, and internal teams.

• Review inpatient medical records to validate principal diagnosis, secondary diagnoses (CC/MCC), procedures, and DRG assignment.

• Analyze payer denials involving: o DRG downgrades o Removal of CC/MCC o Clinical validation denials o Coding validation disputes.

• Prepare clear, concise, and compliant DRG appeal letters supported by:

o ICD-10-CM/PCS Official Guidelines

o UHDDS reporting requirements

o CMS rules and industry references (e.g., AHA Coding Clinic, AHIMA guidance)

• Defend secondary diagnoses and MCC/CC assignments based on provider documentation and coding standards

• Collaborate with clinical reviewers, CDI teams, and revenue cycle leadership to resolve complex cases

• Ensure timely filing of appeals in accordance with payer and client deadlines

• Accurately document appeal outcomes and maintain tracking logs for productivity, quality, and turnaround time

• Participate in quality audits, peer reviews, and continuous process improvement initiatives

• Maintain strict compliance with HIPAA and data privacy regulations.

Required Qualifications:

• Inpatient Coding Experience (required)

• Strong working knowledge of:

o ICD-10-CM and ICD-10-PCS

o MS-DRG and APR-DRG systems

o CC/MCC logic and DRG impact

• Demonstrated experience handling DRG appeals or inpatient coding denials

• Ability to interpret complex medical documentation and translate findings into defensible appeal narratives.

• Excellent written communication skills with the ability to cite official coding and clinical references.

• High attention to detail, critical thinking, and strong analytical skills.

• Ability to work independently while meeting productivity and quality benchmarks

Review inpatient medical records to validate principal diagnosis, secondary diagnoses (CC/MCC), procedures, and DRG assignment.

• Analyze payer denials involving:

o DRG downgrades

o Removal of CC/MCC

o Clinical validation denials

o Coding validation disputes

• Prepare clear, concise, and compliant DRG appeal letters supported by:

o ICD-10-CM/PCS Official Guidelines

o UHDDS reporting requirements

o CMS rules and industry references (e.g., AHA Coding Clinic, AHIMA guidance)

• Defend secondary diagnoses and MCC/CC assignments based on provider documentation and coding standards.

• Collaborate with clinical reviewers, CDI teams, and revenue cycle leadership to resolve complex cases.

• Ensure timely filing of appeals in accordance with payer and client deadlines.

• Accurately document appeal outcomes and maintain tracking logs for productivity, quality, and turnaround time.

• Participate in quality audits, peer reviews, and continuous process improvement initiatives .

• Maintain strict compliance with HIPAA and data privacy regulations.

Required Qualifications.

• Inpatient Coding Experience (required)

• Strong working knowledge of:

o ICD-10-CM and ICD-10-PCS

o MS-DRG and APR-DRG systems

o CC/MCC logic and DRG impact

• Demonstrated experience handling DRG appeals or inpatient coding denials.

• Ability to interpret complex medical documentation and translate findings into defensible appeal narratives.

• Excellent written communication skills with the ability to cite official coding and clinical references .

• High attention to detail, critical thinking, and strong analytical skills.

• Ability to work independently while meeting productivity and quality benchmarks

Join our dedicated team at HBiz where we strive to provide outstanding care and service excellence. We

are currently seeking a highly skilled Clinical Appeals Nurse to play a crucial role in managing medical

denials by providing clinical expertise in the appeals process. This position is ideal for those who excel in

analytical thinking and have a strong background in clinical practice and health information management.

Key Responsibilities:

• Review and analyze clinical documentation, utilization records, and insurance denial rationales to

formulate well-constructed appeal cases.

• Engage in the appeals process for denied claims, ensuring that all appeals are submitted in a timely

manner according to regulatory and insurer-specific requirements.

• Utilize clinical experience and knowledge in accordance with established Milliman or Interqual

guidelines to substantiate medical necessity and appropriate level of care.

• Collaborate with healthcare providers, case managers, and insurance companies to gather

additional information and advocate for proper patient services and reimbursement.

• Interpret and apply ICD-10 coding in the review of medical records to support appeal submissions.

• Maintain accurate and detailed records of all appeals processes, outcomes, and communications.

• Educate clinical staff on best practices, changes in payer requirements, and implications of clinical

documentation and coding standards.

• Active Registered Nurse (RN) license in the Philippines, US licensed preferred

• Minimum of two years of bedside clinical experience in a hospital setting.

• Proficiency with Milliman or Interqual clinical guidelines.

• Strong understanding of ICD-10 coding principles.

• Stay abreast of changes in healthcare regulations, payer policies, and clinical criteria guiding

medical necessity.

Qualifications:

• At least one year of experience in clinical appeals or utilization management.

• Bachelor’s Degree in Nursing (BSN) preferred; minimum of an Associate Degree in Nursing (ADN)

required.

• Excellent written communication skills, with the ability to articulate complex clinical information in

a clear and professional manner for appeal justifications.

• Strong organizational skills and the ability to manage multiple cases simultaneously.

Desired Skills:

• Exceptional critical thinking and problem-solving skills.

• Demonstrated ability to work independently as well as part of a team.

• Commitment to ethical medical practices and compliance with all federal and state regulations.

Remote – Cooper City, FL

Job Summary

The Revenue Cycle Implementation Manager is responsible for supporting and overseeing the end‑to‑end implementation of revenue cycle solutions for healthcare clients, including hospitals, physician practices, and health systems. This leadership role ensures successful onboarding of services and technology by managing project teams, driving strategic execution, and serving as an escalation point for clients.

The Implementation Manager will report to the Implementation/Activation Director and owns the delivery of complex projects from discovery through go‑live and transition to operations. This includes full accountability for all project documentation, governance artifacts, client‑facing materials, and internal records, ensuring consistency, compliance, and clarity across all phases of implementation. The role ensures alignment with client objectives, regulatory standards, and organizational goals.

Key Responsibilities

Implementation Leadership & Strategy

• Lead project level implementation strategy, defining project scope, objectives, deliverables, and success criteria.
• Ensure alignment with organizational priorities, client expectations, and operational readiness.
• Develop detailed implementation plans, timelines, and communication frameworks.

Documentation Ownership & Governance

• Serve as the primary owner of all project documentation, including requirements, workflows, SOPs, training materials, status reports, risk logs, testing documentation, access logs and tracking and post‑go‑live evaluations.
• Develop and maintain documentation standards, naming conventions, version controls, and centralized document repositories.
• Ensure documentation is accurate, comprehensive, audit‑ready, and compliant with HIPAA and organizational policies.
• Review, approve, and distribute all client‑facing documents and ensure timely updates throughout the project lifecycle.
• Assist with development of templates, best practices, and continuous improvements to documentation workflows.

Project & Team Management

• After a ramp‑up period, supervise and mentor Implementation Specialists, offering direction, coaching, and performance feedback.
• Coordinate effectively with cross‑functional teams (IT, Operations, Training, Quality, Analytics, etc.) to ensure timely and successful delivery.
• Monitor project performance, proactively resolving risks, issues, and delays.

Client Relationship & Executive Communication

• Serve as the senior point of contact for clients, managing expectations and providing executive‑level project updates.
• Lead client presentations, status meetings, and stakeholder engagement sessions.
• Document, Escalate and resolve client concerns promptly and professionally.

Workflow Design, System Configuration & Testing Oversight

• Oversee discovery and requirements sessions, validating current‑state processes and designing future‑state workflows for operational efficiency and compliance.
• Ensure appropriate configuration of tools, reporting, denial workflows, and collections processes.
• Approve UAT scripts, test cases, and sign‑off criteria; ensure all testing documentation is completed, accurate, and archived.

Training, Change Management & Go-Live Preparation

• Direct training strategy for internal users and clients, ensuring materials are complete, version‑controlled, and aligned with workflow design.
• Manage change‑management activities, ensuring stakeholder readiness for both system and process change.
• Support go-live planning efforts and ensure smooth transition to operational teams.

Performance Monitoring & Continuous Improvement

• Track early performance metrics post‑go‑live, identify gaps, guide remediation activities, and document lessons learned.
• Maintain documentation of best practices and contribute to ongoing process and methodology improvements across the implementation function.
• Promote a culture of quality, documentation excellence, and continuous enhancement.

Compliance & Risk Management

• Ensure that all phases of implementation adhere to HIPAA, security requirements, and regulatory standards.
• Maintain comprehensive documentation to support audits, compliance reviews, and internal QA checks.

Qualifications

Required

• Bachelor’s degree in Healthcare Administration, Business, or a related field (Master’s preferred).
• 5+ years of experience in healthcare revenue cycle management, with at least 2 years in a leadership or managerial role overseeing implementations or large‑scale projects.
• Deep understanding of the full revenue cycle, including registration, charge capture, coding, billing, AR follow‑up, and denial management.
• Demonstrated success managing cross‑functional teams and implementing multiple concurrent projects.
• Strong leadership, communication, documentation, and stakeholder‑management skills.
• Proficiency with Microsoft Office Suite and project management tools (Smartsheet, MS Project, Visio).

Preferred

• Experience working with major healthcare systems (Epic, Cerner, Meditech, HealthQuest).
• PMP, Lean Six Sigma, CRCR, or similar certifications.
• Experience managing outsourced or offshore RCM vendors or billing partners.
• Proven experience establishing and managing document control processes.

Key Competencies

• Strategic Leadership & Decision‑Making
• Client‑Centric Approach
• Advanced Project Management & Risk Mitigation
• Team Development & Coaching
• Analytical Thinking & Problem‑Solving
• Professional Communication & Executive Presence
• Documentation Excellence & Attention to Detail
• Change Management & Workflow Optimization

Key Responsibilities:

• Review and analyze claims that have been denied due to coding-related issues, including diagnosis codes (ICD-10-CM), procedure codes (CPT/HCPCS), and related modifiers. 
• Identify coding discrepancies, documentation deficiencies, and other factors contributing to claims denials, utilizing a thorough understanding of coding guidelines, industry standards, and regulatory requirements. 
• Collaborate with coding teams, healthcare providers, and revenue cycle stakeholders to obtain necessary documentation and information for claims resubmission. 
• Prepare and support coding‑based appeals by developing clear clinical and coding justifications
• Review medical records, payer policies, and coding guidelines to support appeal arguments
• Conduct in-depth coding audits and analysis to validate the accuracy, completeness, and compliance of coding practices, and ensure alignment with payer requirements. 
• Research and interpret coding guidelines, including updates from coding authorities, to ensure coding accuracy and compliance. 
• Maintain up-to-date knowledge of payer policies, medical necessity criteria, and reimbursement guidelines to accurately evaluate coding denials and appeals. 
• Compile and prepare detailed reports on coding-related denials, identifying patterns, trends, and opportunities for process improvement. 
• Collaborate with the revenue cycle team to develop strategies and initiatives aimed at reducing coding-related denials and improving overall revenue cycle performance. 
• Stay informed about emerging coding trends, changes in coding guidelines, and industry best practices, and provide recommendations for updating coding processes and policies. 
• Participate in coding-related meetings, committees, and training sessions to share insights, contribute to problem-solving, and promote cross-departmental collaboration. 
• Qualifications:
• Certifications: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), or similar certification is required.
• Experience: Minimum of 2-3 years of medical coding or auditing experience and experience with risk adjustment audits, clinical documentation improvement (CDI), and payer audits.
• Knowledge of Coding Systems: Strong knowledge of ICD-10, CPT, and HCPCS coding systems, and familiarity with DRG, E/M coding.
• Bachelor's degree: in Nursing, or any Medical or Health Information Management or a related field.
• Familiarity with medical necessity criteria, payer policies, and reimbursement methodologies. 
• Excellent understanding of revenue cycle processes, claims processing workflows, and denials management. 
• Proficiency in using coding software, encoders, and electronic health record (EHR) systems. 
• Detail-oriented mindset with a high level of accuracy and organizational skills. 
• Effective communication and interpersonal skills to collaborate with coding teams, providers, and other stakeholders. 
• Ability to work independently, prioritize tasks, and meet deadlines in a fast-paced environment. 
• Proficiency in using coding-related software and tools, as well as a high level of computer literacy. 
• Join our dynamic team as a Clinical Coding Analyst and contribute to the resolution of coding-related denials, ensuring accurate and compliant coding practices that maximize reimbursement and support optimal healthcare delivery. 

Key Responsibilities:

Review and analyze claims that have been denied due to coding-related issues, including diagnosis codes (ICD-10-CM), procedure codes (CPT/HCPCS), and related modifiers. 

Identify coding discrepancies, documentation deficiencies, and other factors contributing to claims denials, utilizing a thorough understanding of coding guidelines, industry standards, and regulatory requirements. 

Collaborate with coding teams, healthcare providers, and revenue cycle stakeholders to obtain necessary documentation and information for claims resubmission. 

Prepare and support coding‑based appeals by developing clear clinical and coding justifications

Review medical records, payer policies, and coding guidelines to support appeal arguments

Conduct in-depth coding audits and analysis to validate the accuracy, completeness, and compliance of coding practices, and ensure alignment with payer requirements. 

Research and interpret coding guidelines, including updates from coding authorities, to ensure coding accuracy and compliance. 

Maintain up-to-date knowledge of payer policies, medical necessity criteria, and reimbursement guidelines to accurately evaluate coding denials and appeals. 

Compile and prepare detailed reports on coding-related denials, identifying patterns, trends, and opportunities for process improvement. 

Collaborate with the revenue cycle team to develop strategies and initiatives aimed at reducing coding-related denials and improving overall revenue cycle performance. 

Stay informed about emerging coding trends, changes in coding guidelines, and industry best practices, and provide recommendations for updating coding processes and policies. 

Participate in coding-related meetings, committees, and training sessions to share insights, contribute to problem-solving, and promote cross-departmental collaboration. 

Qualifications:

• Certifications: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), or similar certification is required.Experience: Minimum of 2-3 years of medical coding or auditing experience and experience with risk adjustment audits, clinical documentation improvement (CDI), and payer audits.
• Knowledge of Coding Systems: Strong knowledge of ICD-10, CPT, and HCPCS coding systems, and familiarity with DRG, E/M coding.
• Bachelor's degree: in Nursing, or any Medical or Health Information Management or a related field.
• Familiarity with medical necessity criteria, payer policies, and reimbursement methodologies. 
• Excellent understanding of revenue cycle processes, claims processing workflows, and denials management. 
• Proficiency in using coding software, encoders, and electronic health record (EHR) systems. 
• Detail-oriented mindset with a high level of accuracy and organizational skills. 
• Effective communication and interpersonal skills to collaborate with coding teams, providers, and other stakeholders. 
• Ability to work independently, prioritize tasks, and meet deadlines in a fast-paced environment. 

Proficiency in using coding-related software and tools, as well as a high level of computer literacy. Join our dynamic team as a Clinical Coding Analyst and contribute to the resolution of coding-related denials, ensuring accurate and compliant coding practices that maximize reimbursement and support optimal healthcare delivery. 

You will partner closely with Leadership, Data Engineers, and subject matter experts to productionize models using Databricks (Delta Lake, Unity Catalog, MLflow, Feature Store, Workflows) and modern DevOps practices across our cloud environments.

Key Responsibilities

Lakehouse & Databricks Platform

• Design and maintain Databricks workspaces, clusters, SQL Warehouses, cluster policies, and workspace governance (RBAC, SCIM, SSO, secret scopes).
• Implement robust data pipelines with Delta Lake (ACID tables, Z‑ordering, OPTIMIZE/VACUUM), Delta Live Tables (DAGs, expectations), and Workflows (jobs, task orchestration).
• Set up Unity Catalog for cross-workspace governance: data & model lineage, permissions, catalogs/schemas, data tags, and auditability.
• Operationalize ML models using MLflow (tracking, artifacts, metrics, model registry, approvals, stages: Staging/Production).
• Build/maintain Feature Store entities and feature pipelines; enforce reproducibility and feature governance.
• Establish model deployment patterns (batch scoring, streaming, microservices) using Model Serving.
• Create scalable CI/CD for notebooks, repos, and jobs using Azure DevOps, including unit/integration tests, data/feature validation, and registry promotions.
• Implement data quality and ML quality controls (e.g., Great Expectations/Delta expectations, statistical tests, drift detection, canary releases).
• Build robust monitoring & alerting for data freshness, pipeline SLAs, model performance, drift, and operational metrics.
• Optimize performance and cost (autoscaling, spot instances, DBR runtimes, caching, storage tiers).
• Enforce compliance and security best practices (PII handling, encryption at rest/in transit, network controls, secret management).
• Partner with data engineers and subject matter experts to standardize templates for experiments, pipelines, model packaging, and deployment.
• Document patterns and build internal tooling (CLI utilities, Python packages) to streamline model release and observability.
• Contribute to incident response, post‑mortems, and continuous improvements.

ML Lifecycle & MLOps

• Operationalize ML models using MLflow (tracking, artifacts, metrics, model registry, approvals, stages: Staging/Production).
• Build/maintain Feature Store entities and feature pipelines; enforce reproducibility and feature governance.
• Establish model deployment patterns (batch scoring, streaming, microservices) using Model Serving.
• Create scalable CI/CD for notebooks, repos, and jobs using Azure DevOps, including unit/integration tests, data/feature validation, and registry promotions.
• Implement data quality and ML quality controls (e.g., Great Expectations/Delta expectations, statistical tests, drift detection, canary releases).
• Build robust monitoring & alerting for data freshness, pipeline SLAs, model performance, drift, and operational metrics.
• Operationalize ML models using MLflow (tracking, artifacts, metrics, model registry, approvals, stages: Staging/Production).
• Build/maintain Feature Store entities and feature pipelines; enforce reproducibility and feature governance.
• Establish model deployment patterns (batch scoring, streaming, microservices) using Model Serving.
• Create scalable CI/CD for notebooks, repos, and jobs using Azure DevOps, including unit/integration tests, data/feature validation, and registry promotions.
• Implement data quality and ML quality controls (e.g., Great Expectations/Delta expectations, statistical tests, drift detection, canary releases).
• Build robust monitoring & alerting for data freshness, pipeline SLAs, model performance, drift, and operational metrics.

Infrastructure & Security

• Optimize performance and cost (autoscaling, spot instances, DBR runtimes, caching, storage tiers).
• Enforce compliance and security best practices (PII handling, encryption at rest/in transit, network controls, secret management).

Collaboration & Process

• Partner with data engineers and subject matter experts to standardize templates for experiments, pipelines, model packaging, and deployment.
• Document patterns and build internal tooling (CLI utilities, Python packages) to streamline model release and observability.
• Contribute to incident response, post‑mortems, and continuous improvements.

Qualifications

Required

• BS/MS in Computer Science, Engineering, Data Science, or equivalent practical experience.
• 3+ years of MLOps/ML Engineering/Platform Engineering experience in Databricks.
• Hands‑on expertise with Databricks: Delta Lake, Unity Catalog, MLflow (Tracking/Registry), Feature Store, Workflows/Jobs, Repos, and Model Serving.
• Strong Python engineering skills (packaging, testing, virtual environments); familiarity with Spark (PySpark) and SQL.
• Experience with CI/CD (GitHub Actions/Azure DevOps/GitLab), artifact registries, and environment management.
• Solid understanding of data/machine learning pipeline design (batch/streaming), data quality checks, and ML evaluation/monitoring.

Soft Skills

• Excellent communication and organizational abilities.
• Ability to work independently and as a part of cross-functional teams.
• Comfortable operating in a fast-paced, changing environment.
• Strong analytical and problem-solving skills, with the ability to interpret data and drive recommendations.

HBiz Approval & Disclaimer

This job description is intended to describe the general nature and level of work performed by individuals assigned to this position. It is not intended to be an exhaustive list of all duties, responsibilities, or qualifications required. Responsibilities may change based on business needs, client requirements, or operational priorities.

HBiz reserves the right to modify this job description at any time, with or without notice.

Employment with HBiz is at-will, meaning either the employee or the company may terminate employment at any time, with or without cause or notice, subject to applicable law.

HBiz is an Equal Opportunity Employer and is committed to providing a workplace free from discrimination and harassment. We celebrate diversity and are committed to creating an inclusive environment for all employees.

You will partner closely with Leadership, Data Engineers, and subject matter experts to productionize models using Databricks (Delta Lake, Unity Catalog, MLflow, Feature Store, Workflows) and modern DevOps practices across our cloud environments.

Key Responsibilities

Lakehouse & Databricks Platform

• Design and maintain Databricks workspaces, clusters, SQL Warehouses, cluster policies, and workspace governance (RBAC, SCIM, SSO, secret scopes).
• Implement robust data pipelines with Delta Lake (ACID tables, Z‑ordering, OPTIMIZE/VACUUM), Delta Live Tables (DAGs, expectations), and Workflows (jobs, task orchestration).
• Set up Unity Catalog for cross-workspace governance: data & model lineage, permissions, catalogs/schemas, data tags, and auditability.
• Operationalize ML models using MLflow (tracking, artifacts, metrics, model registry, approvals, stages: Staging/Production).
• Build/maintain Feature Store entities and feature pipelines; enforce reproducibility and feature governance.
• Establish model deployment patterns (batch scoring, streaming, microservices) using Model Serving.
• Create scalable CI/CD for notebooks, repos, and jobs using Azure DevOps, including unit/integration tests, data/feature validation, and registry promotions.
• Implement data quality and ML quality controls (e.g., Great Expectations/Delta expectations, statistical tests, drift detection, canary releases).
• Build robust monitoring & alerting for data freshness, pipeline SLAs, model performance, drift, and operational metrics.
• Optimize performance and cost (autoscaling, spot instances, DBR runtimes, caching, storage tiers).
• Enforce compliance and security best practices (PII handling, encryption at rest/in transit, network controls, secret management).
• Partner with data engineers and subject matter experts to standardize templates for experiments, pipelines, model packaging, and deployment.
• Document patterns and build internal tooling (CLI utilities, Python packages) to streamline model release and observability.
• Contribute to incident response, post‑mortems, and continuous improvements.

ML Lifecycle & MLOps

• Operationalize ML models using MLflow (tracking, artifacts, metrics, model registry, approvals, stages: Staging/Production).
• Build/maintain Feature Store entities and feature pipelines; enforce reproducibility and feature governance.
• Establish model deployment patterns (batch scoring, streaming, microservices) using Model Serving.
• Create scalable CI/CD for notebooks, repos, and jobs using Azure DevOps, including unit/integration tests, data/feature validation, and registry promotions.
• Implement data quality and ML quality controls (e.g., Great Expectations/Delta expectations, statistical tests, drift detection, canary releases).
• Build robust monitoring & alerting for data freshness, pipeline SLAs, model performance, drift, and operational metrics.
• Operationalize ML models using MLflow (tracking, artifacts, metrics, model registry, approvals, stages: Staging/Production).
• Build/maintain Feature Store entities and feature pipelines; enforce reproducibility and feature governance.
• Establish model deployment patterns (batch scoring, streaming, microservices) using Model Serving.
• Create scalable CI/CD for notebooks, repos, and jobs using Azure DevOps, including unit/integration tests, data/feature validation, and registry promotions.
• Implement data quality and ML quality controls (e.g., Great Expectations/Delta expectations, statistical tests, drift detection, canary releases).
• Build robust monitoring & alerting for data freshness, pipeline SLAs, model performance, drift, and operational metrics.

  • Design, deploy, and operate LLMOps pipelines for Retrieval‑Augmented Generation (RAG), including document ingestion, embedding generation, vector storage, retrieval strategies, prompt/version management, and evaluation, using Databricks (Delta Lake, MLflow, Model Serving) to ensure secure, auditable, and production‑grade GenAI systems.

Infrastructure & Security

• Optimize performance and cost (autoscaling, spot instances, DBR runtimes, caching, storage tiers).
• Enforce compliance and security best practices (PII handling, encryption at rest/in transit, network controls, secret management).

Collaboration & Process

• Partner with data engineers and subject matter experts to standardize templates for experiments, pipelines, model packaging, and deployment.
• Document patterns and build internal tooling (CLI utilities, Python packages) to streamline model release and observability.
• Contribute to incident response, post‑mortems, and continuous improvements.

Qualifications

Required

• BS/MS in Computer Science, Engineering, Data Science, or equivalent practical experience.
• 3+ years of MLOps/ML Engineering/Platform Engineering experience in Databricks.
• Hands‑on expertise with Databricks: Delta Lake, Unity Catalog, MLflow (Tracking/Registry), Feature Store, Workflows/Jobs, Repos, and Model Serving.
• Strong Python engineering skills (packaging, testing, virtual environments); familiarity with Spark (PySpark) and SQL.
• Experience with CI/CD (GitHub Actions/Azure DevOps/GitLab), artifact registries, and environment management.
• Solid understanding of data/machine learning pipeline design (batch/streaming), data quality checks, and ML evaluation/monitoring.

Soft Skills

• Excellent communication and organizational abilities.
• Ability to work independently and as a part of cross-functional teams.
• Comfortable operating in a fast-paced, changing environment.
• Strong analytical and problem-solving skills, with the ability to interpret data and drive recommendations.

HBiz Approval & Disclaimer

This job description is intended to describe the general nature and level of work performed by individuals assigned to this position. It is not intended to be an exhaustive list of all duties, responsibilities, or qualifications required. Responsibilities may change based on business needs, client requirements, or operational priorities.

HBiz reserves the right to modify this job description at any time, with or without notice.

Employment with HBiz is at-will, meaning either the employee or the company may terminate employment at any time, with or without cause or notice, subject to applicable law.

HBiz is an Equal Opportunity Employer and is committed to providing a workplace free from discrimination and harassment. We celebrate diversity and are committed to creating an inclusive environment for all employees.

Company Overview:  

For over 20 years, we’ve been a leading middle market revenue cycle management (RCM) vendor, providing comprehensive financial and operational solutions to health systems, physician groups, or specialty medical practices. Our mission is to improve the overall financial health of our clients by offering customized, data-driven, and tech-enabled recovery of denied claims and aged receivables. We utilize our deep expertise in revenue cycle to help transform our client’s revenue cycle processes to achieve sustained reductions in denial rates. 

Key Responsibilities:  

• Review and analyze claims that have been denied due to coding-related issues, including diagnosis codes (ICD-10-CM), procedure codes (CPT/HCPCS), and related modifiers.  

• Identify coding discrepancies, documentation deficiencies, and other factors contributing to claims denials, utilizing a thorough understanding of coding guidelines, industry standards, and regulatory requirements.  

• Collaborate with coding teams, healthcare providers, and revenue cycle stakeholders to obtain necessary documentation and information for claims resubmission.  

• Prepare and support coding‑based appeals by developing clear clinical and coding justifications  

• Review medical records, payer policies, and coding guidelines to support appeal arguments  

• Conduct in-depth coding audits and analysis to validate the accuracy, completeness, and compliance of coding practices, and ensure alignment with payer requirements.  

• Research and interpret coding guidelines, including updates from coding authorities, to ensure coding accuracy and compliance.  

• Maintain up-to-date knowledge of payer policies, medical necessity criteria, and reimbursement guidelines to accurately evaluate coding denials and appeals.  

• Compile and prepare detailed reports on coding-related denials, identifying patterns, trends, and opportunities for process improvement.  

• Collaborate with the revenue cycle team to develop strategies and initiatives aimed at reducing coding-related denials and improving overall revenue cycle performance.  

• Stay informed about emerging coding trends, changes in coding guidelines, and industry best practices, and provide recommendations for updating coding processes and policies.  

• Participate in coding-related meetings, committees, and training sessions to share insights, contribute to problem-solving, and promote cross-departmental collaboration.  

Qualifications:  

• Certifications: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), or similar certification is required. 

• Experience: Minimum of 2-3 years of medical coding or auditing experience and experience with risk adjustment audits, clinical documentation improvement (CDI), and payer audits. 

• Knowledge of Coding Systems: Strong knowledge of ICD-10, CPT, and HCPCS coding systems, and familiarity with DRG, E/M coding. 

• Bachelor's degree: in Nursing, or any Medical or Health Information Management or a related field. 

• Familiarity with medical necessity criteria, payer policies, and reimbursement methodologies.  

• Excellent understanding of revenue cycle processes, claims processing workflows, and denials management.  

• Proficiency in using coding software, encoders, and electronic health record (EHR) systems.  

• Detail-oriented mindset with a high level of accuracy and organizational skills.  

• Effective communication and interpersonal skills to collaborate with coding teams, providers, and other stakeholders.  

• Ability to work independently, prioritize tasks, and meet deadlines in a fast-paced environment.  

• Proficiency in using coding-related software and tools, as well as a high level of computer literacy.  

• Join our dynamic team as a Clinical Coding Analyst and contribute to the resolution of coding-related denials, ensuring accurate and compliant coding practices that maximize reimbursement and support optimal healthcare delivery.  

 Health Business Solutions, LLC provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.  

Company Overview:  

For over 20 years, we’ve been a leading middle market revenue cycle management (RCM) vendor, providing comprehensive financial and operational solutions to health systems, physician groups, or specialty medical practices. Our mission is to improve the overall financial health of our clients by offering customized, data-driven, and tech-enabled recovery of denied claims and aged receivables. We utilize our deep expertise in revenue cycle to help transform our client’s revenue cycle processes to achieve sustained reductions in denial rates. 

Key Responsibilities:  

• Review and analyze claims that have been denied due to coding-related issues, including diagnosis codes (ICD-10-CM), procedure codes (CPT/HCPCS), and related modifiers.  

• Identify coding discrepancies, documentation deficiencies, and other factors contributing to claims denials, utilizing a thorough understanding of coding guidelines, industry standards, and regulatory requirements.  

• Collaborate with coding teams, healthcare providers, and revenue cycle stakeholders to obtain necessary documentation and information for claims resubmission.  

• Prepare and support coding‑based appeals by developing clear clinical and coding justifications  

• Review medical records, payer policies, and coding guidelines to support appeal arguments  

• Conduct in-depth coding audits and analysis to validate the accuracy, completeness, and compliance of coding practices, and ensure alignment with payer requirements.  

• Research and interpret coding guidelines, including updates from coding authorities, to ensure coding accuracy and compliance.  

• Maintain up-to-date knowledge of payer policies, medical necessity criteria, and reimbursement guidelines to accurately evaluate coding denials and appeals.  

• Compile and prepare detailed reports on coding-related denials, identifying patterns, trends, and opportunities for process improvement.  

• Collaborate with the revenue cycle team to develop strategies and initiatives aimed at reducing coding-related denials and improving overall revenue cycle performance.  

• Stay informed about emerging coding trends, changes in coding guidelines, and industry best practices, and provide recommendations for updating coding processes and policies.  

• Participate in coding-related meetings, committees, and training sessions to share insights, contribute to problem-solving, and promote cross-departmental collaboration.  

Qualifications:  

• Certifications: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), or similar certification is required. 

• Experience: Minimum of 2-3 years of medical coding or auditing experience and experience with risk adjustment audits, clinical documentation improvement (CDI), and payer audits. 

• Knowledge of Coding Systems: Strong knowledge of ICD-10, CPT, and HCPCS coding systems, and familiarity with DRG, E/M coding. 

• Bachelor's degree: in Nursing, or any Medical or Health Information Management or a related field. 

• Familiarity with medical necessity criteria, payer policies, and reimbursement methodologies.  

• Excellent understanding of revenue cycle processes, claims processing workflows, and denials management.  

• Proficiency in using coding software, encoders, and electronic health record (EHR) systems.  

• Detail-oriented mindset with a high level of accuracy and organizational skills.  

• Effective communication and interpersonal skills to collaborate with coding teams, providers, and other stakeholders.  

• Ability to work independently, prioritize tasks, and meet deadlines in a fast-paced environment.  

• Proficiency in using coding-related software and tools, as well as a high level of computer literacy.  

• Join our dynamic team as a Clinical Coding Analyst and contribute to the resolution of coding-related denials, ensuring accurate and compliant coding practices that maximize reimbursement and support optimal healthcare delivery.  

 Health Business Solutions, LLC provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.  

The IP Coding Appeals Specialist is responsible for reviewing inpatient (IP) coding denials, preparing and submitting appeals, and ensuring accurate clinical documentation supports appropriate reimbursement. This role works closely with coding, CDI, and payer guidelines to overturn denied claims and optimize revenue recovery. 

Key Responsibilities: 

• Review and analyze inpatient coding denials from payers (e.g., DRG downgrades, medical necessity denials)  

• Interpret medical records to validate accurate ICD-10-CM/PCS coding and DRG assignment  

• Prepare and submit detailed, evidence-based appeal letters within payer timelines  

• Collaborate with Clinical Documentation Improvement (CDI) teams and coders to identify documentation gaps  

• Ensure compliance with payer-specific guidelines, CMS regulations, and coding standards  

• Track appeal outcomes and maintain documentation for reporting and audit purposes  

• Identify denial trends and provide recommendations to reduce future denials  

• Communicate with insurance payers when additional clarification or follow-up is required  

• Maintain productivity and quality standards as defined by the organization  

Qualifications: 

• Bachelor’s degree in Health Information Management, Nursing, or related field (preferred)  

• Minimum 2–4 years of inpatient coding and/or denial appeals experience  

• Strong knowledge of:

• ICD-10-CM and ICD-10-PCS coding systems  

• MS-DRG classification and reimbursement methodologies  

• Medical terminology, anatomy, and physiology  

• Experience handling payer denials and writing appeals (clinical and coding-based)  

• Familiarity with CMS guidelines and commercial payer policies  

Certifications: 

• One of the following required or preferred:  

• CCS (Certified Coding Specialist)  

• CPC (Certified Professional Coder) with inpatient experience  

• RHIT or RHIA  

Skills & Competencies: 

• Strong analytical and critical thinking skills.

• Excellent written communication (for appeal letters)  

• Attention to detail and accuracy  

• Ability to interpret clinical documentation and payer policies  

• Time management and ability to meet deadlines  

• Proficiency in EHR systems and coding/abstracting tools 

 We are seeking a skilled Utilization Review Coordinator (URC) to oversee patient insurance certification, compliance with governmental regulations related to hospital stays, and the prevention of denials. Embedded within our utilization review management platform are clinical criteria guidelines, streamlining the review and documentation process. The Utilization/Risk Management department conducts perspective, concurrent, and retrospective reviews for authorization of Levels of Care (LOCs) and services, engaging with Program Managers, reviewing medical necessity records, and liaising with individuals and their families when necessary. Additionally, the department handles billing and payroll functions.

PRIMARY RESPONSIBILITIES 

• Evaluate patient records to assess severity of illness and intensity of service.
• Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays.
• Conduct initial admission, continuing stay, and 23-hour observation reviews for all patients.
• Manage case reviews in the electronic utilization review system.
• Collaborate with payor sources to communicate clinical information and secure hospital reimbursement.
• Consult with physicians and nursing staff.
• Participate in interdisciplinary care rounds for effective communication with the care team.
• Use escalation pathways to resolve identified issues.
• Document all activities and interactions in the electronic utilization review record.
• Enhance customer satisfaction among patients, families, physicians, internal and external partners, payors, and vendors.
• Submit Initial and Concurrent Authorizations to insurance companies.
• Verify client insurance coverage for authorization submission.
• Coordinate with insurance companies to resolve billing or authorization issues.
• Communicate Billing and Payroll questions from Program Managers and ensure accurate documentation before billing claims.
• Review Service Verification Forms and Time sheets to ensure precise payroll processing.
• Participate in state and local audits.
• Adhere to policies, procedures, regulations, and standards governing the agency.
• Maintain strict confidentiality according to Federal and State guidelines.
• Uphold the Professional Code of Ethics.
• Other duties as assigned.

QUALIFICATIONS

Required: 

• Bachelor’s degree in nursing, physical therapy, medical technician, HIMS, or a related medical field.
• Managed Care or Health Plan experience.
• Detail-oriented.
• Effective oral and written communication skills.
• Moderate computer proficiency – Microsoft Office Suite.
• Team-oriented approach.
• Independent functioning and autonomy.

Strongly preferred qualifications:

• Previous experience in utilization review/management.
• Experience with InterQual and/or Milliman Care Guidelines.

 We are seeking a skilled Utilization Review Coordinator (URC) to oversee patient insurance certification, compliance with governmental regulations related to hospital stays, and the prevention of denials. Embedded within our utilization review management platform are clinical criteria guidelines, streamlining the review and documentation process. The Utilization/Risk Management department conducts perspective, concurrent, and retrospective reviews for authorization of Levels of Care (LOCs) and services, engaging with Program Managers, reviewing medical necessity records, and liaising with individuals and their families when necessary. Additionally, the department handles billing and payroll functions.

PRIMARY RESPONSIBILITIES 

• Evaluate patient records to assess severity of illness and intensity of service.
• Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays.
• Conduct initial admission, continuing stay, and 23-hour observation reviews for all patients.
• Manage case reviews in the electronic utilization review system.
• Collaborate with payor sources to communicate clinical information and secure hospital reimbursement.
• Consult with physicians and nursing staff.
• Participate in interdisciplinary care rounds for effective communication with the care team.
• Use escalation pathways to resolve identified issues.
• Document all activities and interactions in the electronic utilization review record.
• Enhance customer satisfaction among patients, families, physicians, internal and external partners, payors, and vendors.
• Submit Initial and Concurrent Authorizations to insurance companies.
• Verify client insurance coverage for authorization submission.
• Coordinate with insurance companies to resolve billing or authorization issues.
• Communicate Billing and Payroll questions from Program Managers and ensure accurate documentation before billing claims.
• Review Service Verification Forms and Time sheets to ensure precise payroll processing.
• Participate in state and local audits.
• Adhere to policies, procedures, regulations, and standards governing the agency.
• Maintain strict confidentiality according to Federal and State guidelines.
• Uphold the Professional Code of Ethics.
• Other duties as assigned.

QUALIFICATIONS

Required: 

• Bachelor’s degree in nursing, physical therapy, medical technician, HIMS, or a related medical field.
• Managed Care or Health Plan experience.
• Detail-oriented.
• Effective oral and written communication skills.
• Moderate computer proficiency – Microsoft Office Suite.
• Team-oriented approach.
• Independent functioning and autonomy.

Strongly preferred qualifications:

• Previous experience in utilization review/management.
• Experience with InterQual and/or Milliman Care Guidelines.

Now Hiring a Coding and Denial Auditor! 

We’re seeking an experienced Coding Auditor / Denial Auditor to support hospital revenue cycle auditing, denial prevention, and reimbursement accuracy. This role focuses on inpatient and outpatient hospital claims. Physician billing experience a plus. Clinical experience strongly preferred to support medical necessity and documentation review. 

Key Responsibilities 

• Audit hospital inpatient and outpatient coding 

• Review claim denials, underpayments, and appeals 

• Identify coding, documentation, and medical necessity issues 

• Apply ICD‑10‑CM/PCS, CPT, HCPCS and payer rules 

• Support revenue integrity and denial reduction efforts 

• Provide audit feedback and education to coding and revenue cycle teams 

Qualifications 

• Active credential: CCS, CPC, CIC, or CCS‑P 

• 2+ years hospital coding or denial auditing experience 

• revenue cycle and payer guideline knowledge 

• Experience with CMS and commercial payers 

• Clinical background (RN or other) preferred 

Revenue Cycle Denials/ Clinical Coding Quality Auditor identifies training opportunities, and supports continuous quality improvement across the denials team. 

Key Responsibilities: 

• Perform routine audits of denial work, including root cause identification, appeal accuracy, and documentation quality 

• Validate compliance with payer guidelines and internal workflows 

• Provide clear, constructive feedback and assist with training needs 

• Track quality trends and support process improvement initiatives 

• Review Epic account documentation to ensure correct handling and resolution 

Qualifications: 

• 2+ years of experience in revenue cycle, denials, coding, billing, or insurance follow‑up 

• Coding experience (CPC/CCS a plus) 

• Clinical nursing experience 

• Epic experience preferred 

• Strong knowledge of payer rules, denials, and appeal processes

• Detail‑oriented with excellent communication and analytical skills 

Preferred Skills: 

• Experience performing quality audits 

• Understanding of medical terminology and coding concepts 

Key Responsibilities:

1.           Clinical Assessment: Conduct comprehensive clinical assessments of medical records to ensure patients are receiving appropriate care at the correct level of service.

2.           Care Coordination: Collaborate with interdisciplinary healthcare teams to coordinate patient care and treatment plans, ensuring the most cost-effective and clinically appropriate care is provided.

3.           Revenue Cycle Management: Utilize clinical expertise to support revenue cycle processes, including accurate coding, documentation improvement, and compliance with healthcare regulations.

4.           Utilization Review:

a)           Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays

b)           Conduct initial admission, continuing stay, and 23-hour observations reviews for all patients

c)            Support Utilization Review Coordinator team members on cases escalated for level of care determinations

d)           Screen cases for Physician Advisor review

e)            Collaborate with insurance companies on concurrently denied and high risk for denial cases

5.           Documentation Improvement: Identify opportunities for improving clinical documentation to support accurate coding and billing processes, ultimately improving reimbursement.

6.           Data Analysis: Analyze clinical and financial data to identify trends, opportunities for improvement, and areas of potential cost savings for clients.

7.           Compliance: Stay up-to-date with healthcare regulations, guidelines, and policies to ensure all patient care and revenue cycle processes are in compliance with industry standards and regulatory requirements to ensure appropriate reimbursement.

Qualifications:

•          Registered Nurse (RN) licensure required; must hold a USRN multi-state/compact nursing license.

•             Bachelor of Science in Nursing (BSN) preferred.

•             Case Management Certification (e.g., CCM) is a plus.

•             Minimum of 3 years of clinical nursing experience, preferably in a hospital or acute care setting.

•             Strong understanding of revenue cycle management and healthcare reimbursement.

•             Proficiency in medical coding and clinical documentation improvement.

•             Excellent communication, interpersonal, and teamwork skills.

•             Ability to work independently and make sound clinical and financial decisions.

•             Strong analytical and problem-solving skills.

•             Proficient in using healthcare information systems and technology.

•             Commitment to maintaining patient confidentiality and ethical standards.

Benefits:

•             Competitive salary

•             Comprehensive healthcare benefits

•             Professional development and training opportunities

•             Collaborative and supportive work environment

•             Opportunities for advancement within the company

•             Work-life balance programs

Key Responsibilities:

1.           Clinical Assessment: Conduct comprehensive clinical assessments of medical records to ensure patients are receiving appropriate care at the correct level of service.

2.           Care Coordination: Collaborate with interdisciplinary healthcare teams to coordinate patient care and treatment plans, ensuring the most cost-effective and clinically appropriate care is provided.

3.           Revenue Cycle Management: Utilize clinical expertise to support revenue cycle processes, including accurate coding, documentation improvement, and compliance with healthcare regulations.

4.           Utilization Review:

a)           Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays

b)           Conduct initial admission, continuing stay, and 23-hour observations reviews for all patients

c)            Support Utilization Review Coordinator team members on cases escalated for level of care determinations

d)           Screen cases for Physician Advisor review

e)            Collaborate with insurance companies on concurrently denied and high risk for denial cases

5.           Documentation Improvement: Identify opportunities for improving clinical documentation to support accurate coding and billing processes, ultimately improving reimbursement.

6.           Data Analysis: Analyze clinical and financial data to identify trends, opportunities for improvement, and areas of potential cost savings for clients.

7.           Compliance: Stay up-to-date with healthcare regulations, guidelines, and policies to ensure all patient care and revenue cycle processes are in compliance with industry standards and regulatory requirements to ensure appropriate reimbursement.

Qualifications:

•          Registered Nurse (RN) licensure required; must hold a USRN multi-state/compact nursing license.

•             Bachelor of Science in Nursing (BSN) preferred.

•             Case Management Certification (e.g., CCM) is a plus.

•             Minimum of 3 years of clinical nursing experience, preferably in a hospital or acute care setting.

•             Strong understanding of revenue cycle management and healthcare reimbursement.

•             Proficiency in medical coding and clinical documentation improvement.

•             Excellent communication, interpersonal, and teamwork skills.

•             Ability to work independently and make sound clinical and financial decisions.

•             Strong analytical and problem-solving skills.

•             Proficient in using healthcare information systems and technology.

•             Commitment to maintaining patient confidentiality and ethical standards.

Benefits:

•             Competitive salary

•             Comprehensive healthcare benefits

•             Professional development and training opportunities

•             Collaborative and supportive work environment

•             Opportunities for advancement within the company

•             Work-life balance programs

Key Responsibilities:

1.           Leadership and Team Management:

•             Supervise and mentor a team of Utilization Review Nurses, providing guidance and support to ensure excellent performance.

•             Foster a collaborative and cohesive work environment within the department.

•             Conduct regular staff meetings, performance evaluations, and staff development activities.

2.           Care Coordination and Oversight:

•             Oversee the development and implementation of individualized care plans for patients.

•             Collaborate with the healthcare team to ensure coordinated and efficient patient care across different healthcare settings.

•             Monitor and assess the appropriateness of care plans and resource utilization.

3.           Quality Improvement:

•             Implement and monitor quality improvement initiatives to enhance patient outcomes and compliance with healthcare regulations.

•             Analyze data and metrics to identify areas for improvement in care coordination processes.

4.           Budget Management:

•             Manage the department's budget and resource allocation efficiently while maintaining high-quality patient care.

•             Collaborate with finance and administrative teams to optimize resource utilization.

5.           Staff Development:

•             Provide ongoing training and education to Utilization Review Nurses to keep them updated on best practices and regulatory changes.

•             Encourage professional growth and development within the department.

6.           Patient Advocacy:

•             Serve as a patient advocate, ensuring that patients' needs and preferences are addressed throughout their healthcare journey.

•             Participate in complex case reviews and offer guidance on challenging patient cases.

7.           Documentation and Compliance:

•             Ensure accurate and timely documentation of patient records, care plans, and progress notes in accordance with regulatory standards.

Qualifications:

•             Current RN (Registered Nurse) license. PHRN or USRN, Compact or Multi-State License strongly preferred.

•             Bachelor's degree in Nursing (BSN) required Masters (MSN) preferred.

•             Previous experience in case management or care coordination, with at least 2 years in a leadership role.

•             Strong clinical assessment and critical thinking skills.

•             Excellent communication and interpersonal skills.

•             Knowledge of healthcare regulations, insurance processes, and quality improvement methodologies.

•             Proficiency in electronic health records (EHR) and healthcare software.

•             Dedication to patient-centered care and a commitment to ethical practice.

If you are an experienced and visionary nurse leader who is passionate about improving patient care and outcomes, we invite you to apply for the Utilization Review Nurse Manager position. Join our team and lead the way in optimizing patient care. Apply today!

Key Responsibilities:

1.           Leadership and Team Management:

•             Supervise and mentor a team of Utilization Review Nurses, providing guidance and support to ensure excellent performance.

•             Foster a collaborative and cohesive work environment within the department.

•             Conduct regular staff meetings, performance evaluations, and staff development activities.

2.           Care Coordination and Oversight:

•             Oversee the development and implementation of individualized care plans for patients.

•             Collaborate with the healthcare team to ensure coordinated and efficient patient care across different healthcare settings.

•             Monitor and assess the appropriateness of care plans and resource utilization.

3.           Quality Improvement:

•             Implement and monitor quality improvement initiatives to enhance patient outcomes and compliance with healthcare regulations.

•             Analyze data and metrics to identify areas for improvement in care coordination processes.

4.           Budget Management:

•             Manage the department's budget and resource allocation efficiently while maintaining high-quality patient care.

•             Collaborate with finance and administrative teams to optimize resource utilization.

5.           Staff Development:

•             Provide ongoing training and education to Utilization Review Nurses to keep them updated on best practices and regulatory changes.

•             Encourage professional growth and development within the department.

6.           Patient Advocacy:

•             Serve as a patient advocate, ensuring that patients' needs and preferences are addressed throughout their healthcare journey.

•             Participate in complex case reviews and offer guidance on challenging patient cases.

7.           Documentation and Compliance:

•             Ensure accurate and timely documentation of patient records, care plans, and progress notes in accordance with regulatory standards.

Qualifications:

•             Current RN (Registered Nurse) license. PHRN or USRN, Compact or Multi-State License strongly preferred.

•             Bachelor's degree in Nursing (BSN) required Masters (MSN) preferred.

•             Previous experience in case management or care coordination, with at least 2 years in a leadership role.

•             Strong clinical assessment and critical thinking skills.

•             Excellent communication and interpersonal skills.

•             Knowledge of healthcare regulations, insurance processes, and quality improvement methodologies.

•             Proficiency in electronic health records (EHR) and healthcare software.

•             Dedication to patient-centered care and a commitment to ethical practice.

If you are an experienced and visionary nurse leader who is passionate about improving patient care and outcomes, we invite you to apply for the Utilization Review Nurse Manager position. Join our team and lead the way in optimizing patient care. Apply today!

Key Responsibilities:

·       Clinical Assessment: Conduct comprehensive clinical assessments of medical records to ensure patients are receiving appropriate care at the correct level of service.

• Care Coordination: Collaborate with interdisciplinary healthcare teams to coordinate patient care and treatment plans, ensuring the most cost-effective and clinically appropriate care is provided.
• Revenue Cycle Management: Utilize clinical expertise to support revenue cycle processes, including accurate coding, documentation improvement, and compliance with healthcare regulations.

• Utilization Review:

a) Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays

b) Conduct initial admission, continuing stay, and 23-hour observations reviews for all patients

c) Support Utilization Review Coordinator team members on cases escalated for level of care determinations

d) Screen cases for Physician Advisor review

e) Collaborate with insurance companies on concurrently denied and high risk for denial cases

•  Documentation Improvement: Identify opportunities for improving clinical documentation to support accurate coding and billing processes, ultimately improving reimbursement.

• Data Analysis: Analyze clinical and financial data to identify trends, opportunities for improvement, and areas of potential cost savings for clients.

• Compliance: Stay up-to-date with healthcare regulations, guidelines, and policies to ensure all patient care and revenue cycle processes are in compliance with industry standards and regulatory requirements to ensure appropriate reimbursement.

Qualifications:

·       Registered Nurse (RN) licensure required; must hold a USRN multi-state/compact nursing license.

·       Bachelor of Science in Nursing (BSN) preferred.

·       Case Management Certification (e.g., CCM) is a plus.

·       Minimum of 3 years of clinical nursing experience, preferably in a hospital or acute care setting.

·       Minimum 2 years of work experience in Utilization Review

·       Strong understanding of revenue cycle management and healthcare reimbursement.

·       Proficiency in medical coding and clinical documentation improvement.

·       Excellent communication, interpersonal, and teamwork skills.

·       Ability to work independently and make sound clinical and financial decisions.

·       Strong analytical and problem-solving skills.

·       Proficient in using healthcare information systems and technology.

·       Commitment to maintaining patient confidentiality and ethical standards.

As a Revenue Cycle Denials Specialist you are responsible for identifying, investigating, appealing, and 

resolving denied or underpaid healthcare claims to maximize reimbursement and minimize 

revenue leakage. The role works closely with payers, providers, coding teams, clinical staff, and 

billing departments to ensure timely resolution of denied claims while maintaining compliance with 

payer and regulatory requirements.

Key Responsibilities:

• Review and analyze denied, rejected, and underpaid claims to determine root causes.

• Research payer policies, contracts, and reimbursement guidelines to support appeals and 

claim resolution.

• Prioritize denial inventory based on financial impact and timely filing requirements.

• Identify trends and recurring denial patterns and recommend corrective actions.

• Prepare and submit high-quality first-level, second-level, and administrative appeals. 

• Draft appeal letters supported by clinical documentation, coding guidelines, and payer 

policies. 

• Follow up with insurance carriers to ensure timely review and adjudication of appealed 

claims

• Maximize reimbursement through effective claim correction, reconsideration requests, 

and appeals. 

• Monitor aging denial accounts and ensure timely resolution. 

• Track recovered revenue and maintain performance metrics.

Qualifications

• College grad. or equivalent (Bachelor’s degree preferred

• Minimum 2 years of experience in healthcare revenue cycle management specifically denial management (denied claims

• Understanding of ICD-10-CM, CPT, HCPCS, and medical necessity guidelines.

• Experience with electronic health records (EHR) and billing systems.

• Certified Professional Biller (CPB), Certified Revenue Cycle Representative (CRCR), or 

similar certification is a plus.

• Experience in hospital, physician practice, or healthcare outsourcing/BPO environments is 

preferred.

• Technical appeal writing experience preferred.

• Familiarity with payer portals and denial management software.

• Proficiency in Microsoft Excel, Word, and revenue cycle applications. 

• Knowledge of healthcare reimbursement methodologies.

As a Revenue Cycle Denials Specialist you are responsible for identifying, investigating, appealing, and 

resolving denied or underpaid healthcare claims to maximize reimbursement and minimize 

revenue leakage. The role works closely with payers, providers, coding teams, clinical staff, and 

billing departments to ensure timely resolution of denied claims while maintaining compliance with 

payer and regulatory requirements.

Key Responsibilities:

• Review and analyze denied, rejected, and underpaid claims to determine root causes.

• Research payer policies, contracts, and reimbursement guidelines to support appeals and 

claim resolution.

• Prioritize denial inventory based on financial impact and timely filing requirements.

• Identify trends and recurring denial patterns and recommend corrective actions.

• Prepare and submit high-quality first-level, second-level, and administrative appeals. 

• Draft appeal letters supported by clinical documentation, coding guidelines, and payer 

policies. 

• Follow up with insurance carriers to ensure timely review and adjudication of appealed 

claims

• Maximize reimbursement through effective claim correction, reconsideration requests, 

and appeals. 

• Monitor aging denial accounts and ensure timely resolution. 

• Track recovered revenue and maintain performance metrics.

Qualifications

• College grad. or equivalent (Bachelor’s degree preferred)

• Minimum 2 years of experience in healthcare revenue cycle management specifically denial management (denied claims inventory/collection)

• Understanding of ICD-10-CM, CPT, HCPCS, and medical necessity guidelines.

• Experience with electronic health records (EHR) and billing systems.

• Certified Professional Biller (CPB), Certified Revenue Cycle Representative (CRCR), or 

similar certification is a plus.

• Experience in hospital, physician practice, or healthcare outsourcing/BPO environments is 

preferred.

• Technical appeal writing experience preferred.

• Familiarity with payer portals and denial management software.

• Proficiency in Microsoft Excel, Word, and revenue cycle applications. 

• Knowledge of healthcare reimbursement methodologies.

The AVP of Revenue Cycle Operations is responsible for the execution, performance, and financial outcomes of assigned revenue cycle service lines or large, multi-market client programs. This role provides senior operational leadership across multiple geographies, translating enterprise strategy set by the SVP into consistent, high-quality delivery. The AVP owns day-to-day operational execution, client performance, and risk management while ensuring scalability, margin discipline, and client satisfaction.

Key Responsibilities

Operational Leadership & Execution

• Provide operational leadership for assigned service lines or large, multi-market engagements
• Ensure consistent execution of revenue cycle workflows across markets, teams, and client environments
• Own service line or program performance against KPIs, SLAs, and contractual obligations
• Identify operational risks and lead timely mitigation and resolution efforts

Financial & Performance Management

• Own financial performance at the service line or program level, including staffing models, productivity, and margin performance
• Partner with the SVP to develop and manage budgets, forecasts, and cost controls
• Drive continuous improvement initiatives to optimize efficiency and profitability

Client & Stakeholder Management

• Serve as the senior operational point of contact for assigned clients and programs
• Lead executive level client discussions related to performance, issue resolution, and operational strategy

Leadership & Talent Development

• Lead, mentor, and develop Directors and Senior Managers across markets
• Ensure leadership alignment, clear accountability, and performance management across teams
• Support succession planning and leadership bench development within Operations

Process, Standardization & Scalability

• Translate enterprise strategy and operating standards into repeatable, scalable execution models
• Drive standardization of workflows, KPIs, and best practices across markets
• Support implementation of system enhancements, automation, and process optimization initiatives

Qualifications

Required

• Bachelor’s degree in Healthcare Administration, Business, or related field (Master’s preferred)
• 8–12+ years of progressive experience in healthcare revenue cycle operations
• Demonstrated leadership experience overseeing multi-market or large-scale revenue cycle programs
• Strong financial acumen, including budgeting, forecasting, and margin management
• Proven ability to lead senior operational leaders and drive performance at scale

Preferred

• Experience in a healthcare revenue cycle vendor or managed services environment
• Experience leading complex service lines (e.g., end-to-end RCM, AR, coding, patient access)
• Familiarity with major EHR and RCM platforms (e.g., Epic, Cerner, Meditech)
• Experience working with private equity–backed or high-growth organizations

Key Competencies

• Executive operational leadership
• Financial and margin discipline
• Client relationship management
• Strategic execution
• Change management and scalability
• Data-driven decision-making

Success Measures

• Achievement of service line or program KPIs, SLAs, and margin targets
• Improved operational consistency and scalability across markets
• Strong client satisfaction and retention
• Effective leadership development and team performance
• Successful execution of enterprise initiatives at the operational level

Health Business Solutions (HBiz) is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all employees and applicants without regard to race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability, genetic information, veteran status, or any other status protected by applicable federal, state, or local law.

HBiz complies with all applicable employment laws for remote and multi-state hiring and provides reasonable accommodations as required by law.

Location: Remote Employment Type: Full‑Time

Position Summary

Health Business Solutions (HBiz) is seeking an experienced and strategic Senior Manager, Clinical & Coding to lead and oversee clinical and coding operations across government and commercial payers, including post-pay audit. This role is responsible for managing end‑to‑end clinical and coding audit activities, ensuring regulatory compliance, driving audit accuracy, and optimizing financial and operational outcomes for our clients. The Senior Manager will provide leadership to multidisciplinary audit teams, support complex audit responses, analyze trends, and partner with internal and external stakeholders to mitigate risk and improve documentation, coding, and reimbursement practices.

The ideal candidate is a strong people leader with deep expertise in clinical validation, coding compliance, and post‑pay audit methodologies, who thrives in a fast‑paced, remote environment and can manage multiple priorities while maintaining high quality standards.

Key Responsibilities

Audit Oversight & Strategy

• Lead and oversee clinical and coding audits, including government and commercial payer audits (e.g., RAC, MAC, CERT, PERM, TPE, and commercial payer reviews).
• Direct audit intake, medical record review, clinical validation, coding accuracy assessments, quality assurance, and final deliverables.
• Ensure audits are conducted in accordance with CMS regulations, official coding guidelines, payer policies, and internal compliance standards.

Clinical & Coding Expertise

• Provide subject‑matter expertise in ICD‑10‑CM/PCS, CPT, HCPCS, MS‑DRG/APR‑DRG validation, and clinical documentation integrity.
• Review complex, high‑risk audit findings and support defensible, well‑documented outcomes.
• Partner with clinical, coding, and appeals teams to support rebuttals, appeals, and education initiatives as needed.

Leadership & Team Management

• Manage, mentor, and develop a team of clinical auditors, coding auditors, and audit leads, including onshore and offshore resources where applicable.
• Assign workloads, monitor productivity and quality metrics, and ensure timely completion of audits.
• Foster a culture of collaboration, accountability, and continuous improvement.

Reporting, Analytics & Risk Mitigation

• Track audit outcomes, denial trends, and financial impact across clients and payers.
• Develop and present audit performance reports, dashboards, and executive‑level summaries.
• Identify systemic risks and recommend proactive strategies to reduce future audit exposure and improve compliance.

Client & Stakeholder Collaboration

• Serve as a senior point of contact for clients, providing guidance on audit strategy, findings, and risk mitigation.
• Collaborate with internal leadership, operations, and clinical teams to align audit activities with organizational goals.
• Support business development efforts by contributing audit expertise to proposals, client discussions, and service enhancements.
  

Lead complex DRG denial reviews and appeals, conducting comprehensive clinical and coding validation to identify inaccurate payer determinations, support overturn efforts, and maximize reimbursement recovery for inpatient claims.

• Establish and maintain standardized denial management workflows, audit programs, and escalation processes to improve appeal success rates and reduce future denials.
• Develop and monitor DRG denial metrics, recovery rates, and payer performance dashboards, presenting findings and strategic recommendations to executive leadership.
• Provide expert oversight of clinical documentation, coding practices, and regulatory requirements affecting DRG assignment and reimbursement.

Qualifications

Required

• Bachelor’s degree in Nursing.
• 7+ years of progressive experience in healthcare auditing, with significant focus on clinical and coding post‑pay audits.
• 1+ years of experience in people leadership with responsibility for training, coaching, and providing performance feedback
• Demonstrated leadership experience managing audit teams and complex audit programs.
• Strong working knowledge of CMS regulations, official coding guidelines, and payer audit processes.
• Professional credentials such as RHIA, RHIT, CCS, CCS‑P, CPC, CPMA, RN, or equivalent.

Preferred

• Experience with audit tracking systems, EHRs, and performance dashboards.
• Prior experience supporting audit appeals and rebuttals.

Skills & Competencies

• Excellent analytical, communication, and presentation skills.
• Ability to manage multiple projects and deadlines in a remote environment.
• High attention to detail with strong problem‑solving and decision‑making capabilities.
• Collaborative leadership style with a client‑focused mindset. 

The Zero Balance Review (ZBR) Manager leads the operational execution, performance management, and financial outcomes of a hospital revenue cycle program focused on identifying and recovering additional reimbursement from accounts that have reached a zero balance.

Key Responsibilities:

1. Zero Balance:
   1. Evaluate account-level reimbursement opportunities and develop targeted recovery strategies.
   2. Manage production teams to ensure timely execution, quality outcomes, and measurable financial performance.
   3. Identify missed reimbursement opportunities, inappropriate contractual adjustments, and other payment discrepancies that may not have been detected during initial accounts receivable or denial management processes
2. Leadership:
   1. Provide leadership and direction to the revenue cycle team, including billing, coding, claims, collections, and payment posting staff.
   2. Recruit, train, and develop team members to ensure high performance and professional growth.
   3. Conduct regular performance evaluations and provide feedback and coaching to team members. 
3. Revenue Cycle Optimization:
   1. Develop and implement strategies to improve revenue cycle processes and increase efficiency.
   2. Monitor key performance indicators (KPIs) and develop action plans to address areas of improvement.
   3. Utilize data analytics to identify trends, issues, and opportunities for revenue enhancement.
4. Claims Management:
   1. Manage the claims submission process, including electronic and paper claims.
   2. Monitor claim denials and rejections and develop strategies to reduce denial rates.
   3. Work with payers to resolve claim issues and ensure timely reimbursement.
5. Collections and Payment Posting:
   1. Oversee the collections process to ensure timely and accurate patient payments.
   2. Develop and implement policies and procedures for payment posting and reconciliation.
   3. Manage patient accounts and resolve billing inquiries and disputes.
6. Compliance and Regulations:
   1. Ensure compliance with federal, state, and local regulations, including HIPAA and other healthcare laws.
   2. Stay updated on changes in healthcare regulations and payer requirements.
   3. Implement and enforce policies and procedures to maintain compliance.
7. Reporting and Analytics:
   1. Prepare and present regular reports on revenue cycle performance to senior management.
   2. Utilize data analytics to identify trends, issues, and opportunities for improvement.
   3. Develop and implement dashboards and other tools to monitor revenue cycle metrics.
8. All Other Duties as Assigned

Qualifications:

Required Expertise

1. Hospital billing and revenue cycle operations
2. Payer reimbursement methodologies and claim adjudication
3. Contractual payment terms, underpayment review, and insurance follow-up

General Qualifications:

1. Bachelor’s degree in Healthcare Administration, Business Administration, Finance, or related field. Master’s degree preferred.
2. Minimum of 5 years of experience in revenue cycle management, with at least 2 years in a supervisory or managerial role.
3. Strong knowledge of healthcare billing, coding, claims processing, and collections.
4. Familiarity with healthcare regulations, including HIPAA and payer requirements.
5. Proficiency in revenue cycle management software and electronic health record (EHR) systems.
6. Excellent leadership, communication, and interpersonal skills.
7. Strong analytical and problem-solving abilities.

Ability to work in a fast-paced and dynamic environment.

Health Business Solutions (HBiz) is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all employees and applicants without regard to race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability, genetic information, veteran status, or any other status protected by applicable federal, state, or local law.

HBiz complies with all applicable employment laws for remote and multi-state hiring and provides reasonable accommodations as required by law.

The Revenue Cycle Operations Director will oversee all aspects of the revenue cycle, from billing and coding to claims processing and collections. This role will be responsible for ensuring the efficiency, accuracy, and financial integrity of revenue cycle processes, driving improvement initiatives, and ensuring compliance with industry regulations. The Director will collaborate with key departments such as business intelligence, sales, and operations to optimize revenue cycle functions and align with the overall company strategy.

Key Responsibilities:

Leadership and Strategy:

• • Lead, manage, and mentor the revenue cycle management team, ensuring a high level of engagement and productivity.
  • Develop and implement strategies to improve revenue cycle processes, reduce denials, and enhance revenue capture.
  • Analyze revenue cycle trends, including key performance indicators (KPIs), to develop improvement strategies that align with company goals.

Revenue Cycle Management:

• Oversee all functions of the revenue cycle, including patient registration, coding, billing, claims processing, payment posting, denial management, and collections.
• Collaborate with departments such as operations, business intelligence, and sales to improve workflows and achieve revenue optimization.
• Develop and maintain policies and procedures related to revenue cycle activities, ensuring compliance with healthcare regulations and payer requirements.
• Ensure timely and accurate submission of claims and the effective management of accounts receivable to maintain optimal cash flow.

Team Collaboration:

• Work closely with the operations and business intelligence teams to create streamlined workflows and reduce operational inefficiencies.
• Coordinate with the sales and growth department to identify new opportunities and ensure revenue cycle readiness for expanded service lines or contracts.

Process Improvement and Optimization:

• Identify and implement revenue cycle improvements, using data-driven analysis to reduce claim denials, shorten revenue cycle time, and enhance payment collections.
• Introduce automation or technological solutions where possible to improve efficiency in revenue cycle processes.
• Monitor regulatory changes that impact revenue cycle operations and ensure compliance with federal, state, and payer guidelines.

Financial Oversight:

• Work closely with finance and executive leadership to create revenue cycle financial reports and contribute to strategic planning.
• Manage and monitor the departmental budget, making adjustments as necessary to optimize resource allocation and performance.

Compliance and Reporting:

• Ensure adherence to all federal, state, and local laws and regulations related to billing, coding, and collections.
• Prepare and present regular reports on revenue cycle performance, including KPIs, for executive leadership.
• Conduct audits to ensure the accuracy and integrity of revenue cycle operations.

Qualifications:

• Bachelor’s degree in Business Administration, Healthcare Management, Finance, or a related field (Master’s preferred).
• 7+ years of experience in revenue cycle management, with at least 3 years in a leadership role.
• Strong understanding of healthcare billing and coding, payer regulations, and revenue cycle processes.
• Proven experience in developing and implementing process improvements.
• Excellent analytical, problem-solving, and decision-making skills.
• Ability to work collaboratively with cross-functional teams and executive leadership.
• Strong organizational and leadership abilities, with experience managing large teams.
• Excellent communication and presentation skills.

Preferred Skills:

• Familiarity with revenue cycle management software and tools (e.g., Epic, Cerner, Athenahealth).
• Knowledge of healthcare revenue cycle KPIs and best practices for improving metrics like Days in Accounts Receivable (AR), denial rates, and collections.

Health Business Solutions (HBiz) is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all employees and applicants without regard to race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability, genetic information, veteran status, or any other status protected by applicable federal, state, or local law.

HBiz complies with all applicable employment laws for remote and multi-state hiring and provides reasonable accommodations as required by law.

Status: Exempt Location: Remote Department: Clinical Appeals Reports To: Director of Clinical Appeals

Position Overview

The Clinical Appeals Nurse supports HBiz’s revenue cycle operations by reviewing denied claims for clinical accuracy and medical necessity, developing evidence-based appeal strategies, and drafting payer-ready appeal documentation. This role plays a critical part in overturning denials, improving reimbursement outcomes, and ensuring compliance with payer policies and clinical standards.

Key Responsibilities

• Review medical records and payer denial rationale to determine appeal opportunities
• Assess medical necessity using clinical guidelines, payer policies, and regulatory standards
• Draft clear, concise, and evidence-based appeal letters for multiple levels of appeal
• Collaborate with coding, CDI, denial recovery, and operations teams to strengthen appeal strategy
• Identify documentation gaps and recommend improvements to reduce future denials
• Support peer-to-peer review preparation and provide clinical insight when needed
• Track appeal outcomes and contribute to reporting on overturn rates and trends
• Maintain compliance with HIPAA, payer requirements, and client confidentiality standards
• Participate in process improvement initiatives to enhance appeal success and efficiency

 Qualifications

Required

• Active Registered Nurse (RN) license in the United States
• Minimum 3–5 years of clinical nursing experience
• Strong understanding of medical necessity criteria and payer review processes
• Experience reviewing medical records and clinical documentation
• Excellent written communication skills with the ability to translate clinical information into persuasive appeal narratives

Preferred

• Prior experience in utilization review, case management, CDI, or clinical appeals
• Familiarity with CMS guidelines, InterQual, Milliman, or similar criteria
• Experience in hospital or payer-facing environments
• Bachelor of Science in Nursing (BSN)

Core Competencies

• Clinical judgment and analytical thinking
• Strong written and verbal communication
• Detail-oriented documentation review
• Ability to manage multiple appeals and deadlines
• Collaboration across clinical and operational teams

Success Measures

• Appeal overturn rate and recovery contribution
• Quality and clarity of appeal documentation
• Timeliness of appeal submission
• Identification of systemic denial trends and improvement opportunities

HBiz Work Environment

HBiz partners with healthcare organizations nationwide to improve revenue performance and operational efficiency. This role requires strong clinical reasoning, adaptability, and collaboration across departments to ensure our clients receive appropriate reimbursement for medically necessary services.

HBiz Approval & Disclaimer

This job description is intended to describe the general nature and level of work performed by individuals assigned to this position. It is not intended to be an exhaustive list of all duties, responsibilities, or qualifications required. Responsibilities may change based on business needs, client requirements, or operational priorities.

HBiz reserves the right to modify this job description at any time, with or without notice.

Employment with HBiz is at-will, meaning either the employee or the company may terminate employment at any time, with or without cause or notice, subject to applicable law.

HBiz is an Equal Opportunity Employer and is committed to providing a workplace free from discrimination and harassment. We celebrate diversity and are committed to creating an inclusive environment for all employees.

We are seeking an experienced and highly organized Manager of Clinical Appeals to lead our clinical appeals operations across commercial and government payers. This role is responsible for overseeing day-to-day activities of clinical appeal specialists, managing appeal strategy execution, ensuring quality and compliance, and meeting client-specific performance goals.

The ideal candidate brings a strong background in clinical review, medical necessity denials, payer appeal processes, and team leadership—ideally across both U.S. and offshore teams (e.g., Philippines). This position is critical to ensuring timely and effective resolution of denied claims, supporting revenue recovery efforts, and maintaining payer and regulatory compliance.

Key Responsibilities:

• Manage the full-cycle clinical appeals process across multiple payer types, with a focus on government (e.g., Medicare, Medicaid) and commercial payers.
• Lead and support a team of nurses, clinical reviewers, and appeal specialists—including potential offshore (Philippines-based) staff.
• Monitor appeal workloads, productivity, and turnaround times to ensure all appeal deadlines and client service level agreements (SLAs) are met.
• Review and approve complex or high-value clinical appeal cases, ensuring clinical accuracy and compliance with payer guidelines.
• Maintain up-to-date knowledge of medical necessity criteria, payer policies, NCDs/LCDs, and applicable CMS regulations.
• Train new and existing team members on clinical guidelines, appeal writing standards, and regulatory requirements.
• Work cross-functionally with audit, legal, compliance, and operations teams to align on strategy and escalate trends or systemic payer issues.
• Identify and implement process improvements to increase efficiency, reduce denials, and improve overturn rates.
• Support the creation and refinement of appeal templates, clinical arguments, and documentation standards.
• Generate and deliver performance and quality reports to leadership, identifying risks and opportunities for improvement.

Qualifications:

• Registered Nurse (RN) or clinical degree required; Bachelor's degree in Nursing, Health Administration, or related field preferred.
• 5+ years of experience in clinical appeals, utilization review, or medical necessity denials.
• 2+ years in a leadership or supervisory role, preferably within a revenue cycle or payer appeals setting.
• In-depth understanding of payer denial processes, especially Medicare Advantage, Medicaid Managed Care, and commercial plans.
• Experience managing remote and/or offshore teams (Philippines experience preferred).
• Strong working knowledge of ICD-10, CPT, and HCPCS coding as they relate to clinical justifications.
• Excellent writing skills and the ability to clearly communicate complex clinical reasoning.
• Familiarity with appeal submission portals, EHRs, and workflow platforms.
• Knowledge of HIPAA, CMS, and NCQA standards.

Status: Non-Exempt   Department: Coding Reports To: Coding Director Work Location: Remote

Position Summary

The Certified Coder is responsible for performing accurate and compliant coding of inpatient (IP) and outpatient (OP) medical records to support timely billing and maximize revenue integrity. This role ensures correct diagnostic and procedural coding in accordance with ICD-10-CM, CPT, HCPCS, CMS guidelines, and payer-specific requirements.

The Certified Coder works closely with billing teams, clinical staff, and auditors to support clean claim submissions, reduce denials, and promote optimal reimbursement while maintaining the highest standards of coding compliance and data integrity.

Key Responsibilities

• Review, analyze, and accurately assign ICD-10-CM, CPT, and HCPCS codes for inpatient and outpatient encounters, including surgeries, ancillary services, ER, observation, and clinic visits.
• Validate documentation to ensure it supports assigned codes and meets regulatory, compliance, and payer-specific rules.
• Collaborate with providers to obtain missing documentation or clarification using compliant query processes.
• Ensure coding meets all CMS, OIG, HIPAA, and organizational standards for accuracy, integrity, and compliance.
• Assist billing and denial teams with coding-related claim edits, rejections, and appeals.
• Monitor coding trends to identify root causes of denials, documentation gaps, or training opportunities.
• Participate in internal audits, external audits, and quality reviews to support continuous improvement and compliance readiness.
• Meet or exceed established productivity and accuracy benchmarks defined by the RCM department.
• Maintain knowledge of annual coding updates, payer policy changes, and regulatory guidance.
• Protect patient confidentiality and follow all HIPAA and information-security requirements, including secure remote work practices.
• Perform additional related duties as assigned to support departmental and organizational needs.

Required Qualifications

• High school diploma or equivalent required.
• Active certification through AAPC (CPC, CRC, COC) or AHIMA (CCS, CCS-P) required and must be maintained in good standing.
• Minimum 2–3 years of professional coding experience in inpatient and outpatient settings.
• Strong knowledge of ICD-10-CM, CPT/HCPCS, MS-DRG assignment, APC methodology, NCCI edits, LCD/NCD rules, and payer-specific guidelines.
• Demonstrated ability to interpret clinical documentation and assign accurate codes.
• Experience using EHR and coding platforms (Epic, Cerner, Meditech, etc.).
• Strong analytical, organizational, and communication skills.
• Ability to work independently and meet deadlines in a fast-paced RCM environment.

 Preferred Qualifications

• Experience working in a Revenue Cycle Management company or large health system.
• Familiarity with denial management, coding edits, and appeals.
• Knowledge of Medicare, Medicaid, and commercial payer policies.
• Advanced computer skills, including Excel and coding analytics tools.
• Experience participating in coding audits or education initiatives.

Core Competencies

• Critical Thinking & Root Cause Analysis
• Attention to Detail and Coding Accuracy
• Time Management & Productivity Focus
• Problem-Solving & Decision-Making
• Professional Communication
• Regulatory & Compliance Awareness

 Physical & Work Requirements

• Prolonged periods of sitting and computer use.
• Must maintain a secure remote work environment that protects PHI and company systems.
• Ability to work independently with minimal supervision while maintaining productivity and quality standards.

Job Type

Full-Time

Benefits

• 401(k) with employer match
• Health, Dental, and Vision Insurance
• Life Insurance
• Paid Time Off

 Equal Opportunity Statement

HBiz is an Equal Opportunity Employer and does not discriminate based on race, color, religion, sex, national origin, age, disability, genetic information, veteran status, or any other protected classification under applicable federal, state, or local law.

 Job Description Disclaimer

This job description is intended to describe the general nature and level of work performed by employees in this role. It is not intended to be an exhaustive list of all duties, responsibilities, or qualifications. HBiz reserves the right to modify duties or assign additional responsibilities as business needs evolve.

Key Responsibilities

• Serve as the first point of contact for employees regarding HR policies, procedures, and programs.
• Support the full employee lifecycle, including recruitment, onboarding, performance management, and offboarding.
• Advise managers and employees on employee relations issues, conflict resolution, and performance improvement.
• Administer and maintain HR programs such as benefits, leave of absence, compliance training, and wellness initiatives.
• Assist in compensation and payroll administration, ensuring accuracy and timeliness.
• Maintain HRIS records and generate reports/analytics to support decision-making.
• Ensure compliance with federal, state, and local employment laws and regulations.
• Participate in the development and implementation of HR policies, procedures, and initiatives that align with organizational goals.
• Support diversity, equity, and inclusion efforts to strengthen workplace culture.
• Assist in training and development programs to enhance leadership and employee skills.

Qualifications

• Bachelor’s degree in Human Resources, Business Administration, or a related field (or equivalent experience).
• 3+ years of experience in progressive HR roles.
• Substantial experience in recruitment and recruitment best practices. 
• Previous experience in a start-up or rapidly scaling business.
• Experience supporting multi-state or global employee populations.
• Strong background in multistate compliance.
• Solid understanding of HR best practices, employment law, and compliance.
• Strong interpersonal and communication skills with the ability to build trusted relationships.
• Proficiency with HRIS systems and Microsoft Office Suite.
• Ability to handle confidential information with integrity and discretion.
• Strong problem-solving and organizational skills with attention to detail.

Preferred Skills

• Professional HR certification (PHR, SHRM-CP, or equivalent).
• Exposure to talent development and change management initiatives.

Health Business Solutions (HBiz) is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all employees and applicants without regard to race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability, genetic information, veteran status, or any other status protected by applicable federal, state, or local law.

HBiz complies with all applicable employment laws for remote and multi-state hiring and provides reasonable accommodations as required by law.

Summary: The Denial Management Team Lead provides day-to-day leadership, coaching, and operational oversight for a team responsible for resolving denied, rejected, and underpaid healthcare claims. This role drives team performance against quality, productivity, aging, revenue recovery, and service-level targets; manages workload and escalations; and guides the preparation of accurate appeals, reconsiderations, and claim corrections. The Team Lead also analyzes denial trends, coordinates with payers, providers, coding, clinical, billing, and client stakeholders, and implements corrective actions that maximize reimbursement, reduce revenue leakage, and maintain compliance with payer, client, and regulatory requirements.

Key Responsibilities:

• Lead, coach, and develop Denials Specialists to meet quality, productivity, revenue recovery, aging, and service-level targets.
• Review, prioritize, and resolve denied, rejected, and underpaid claims based on root cause, financial impact, payer requirements, and timely filing deadlines.
• Prepare and submit accurate appeals, reconsiderations, and claim corrections supported by clinical documentation, coding guidelines, contracts, and payer policies.
• Serve as the escalation point for complex denials, payer disputes, and appeal challenges, coordinating with payers and internal stakeholders through resolution.
• Analyze denial trends and recurring issues, partner with coding, billing, clinical, and client teams, and lead corrective and preventive process improvements.
• Monitor team performance, workloads, backlogs, staffing coverage, and quality results; provide feedback, training, and performance improvement support as needed.
• Track recovered revenue and operational metrics, maintain audit-ready records, and communicate results, risks, and action plans to management and stakeholders.
• Ensure adherence to standard operating procedures, client requirements, confidentiality standards, and applicable healthcare regulations.

Qualifications  

• College graduate or equivalent (bachelor’s degree preferred)
• Minimum 2 years of experience in healthcare revenue cycle management specifically denial management (denied claims inventory/collection)

• At least 1 year of experience in a team lead, senior specialist, subject matter expert, or comparable leadership role within healthcare revenue cycle or denial management.
• Experience using performance data, quality results, and behavioral observations to identify coaching needs and create individualized development plans.
• Strong analytical and problem-solving skills, with experience interpreting denial trends, operational reports, and performance metrics to drive corrective action.
• Excellent written and verbal communication, stakeholder management, conflict resolution, prioritization, and escalation-handling skills.
• Experience conducting quality reviews, identifying skill gaps, and implementing action plans that improve team accuracy, efficiency, and revenue recovery.
• Ability to interpret payer policies, client procedures, and healthcare compliance requirements and translate them into clear guidance for team members.
• Understanding of ICD-10-CM, CPT, HCPCS, and medical necessity guidelines.
• Working knowledge of Diagnosis-Related Groups (DRGs), including inpatient reimbursement methodologies, coding principles, and their impact on claim denials and appeals.
• Experience with electronic health records (EHR) and billing systems.

• Certified Professional Biller (CPB), Certified Revenue Cycle Representative (CRCR), or similar certification is a plus.
• Experience in hospital, physician practice, or healthcare outsourcing/BPO environments is preferred.
• Technical appeal writing experience preferred.
• Familiarity with payer portals and denial management software.

• Proficiency in Microsoft Excel, Word, and revenue cycle applications.
• Knowledge of healthcare reimbursement methodologies.