Director of Resolutions & Appeals

This job is no longer active. View similar jobs.

POST DATE 8/27/2016
END DATE 12/19/2016

Equian Denver, CO

Denver, CO
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #


JOB TITLE: Director of Resolutions & Appeals

REPORTS TO: VP of Operations

LOCATION: Lakewood, CO


Equian is a healthcare information services company focused on lowering the cost of care by eliminating waste. One of our nation's most pressing challenges is the rising cost and affordability of healthcare. At Equian, all of our efforts are dedicated to addressing this challenge. Equian has grown to become one of the nation's leading companies for healthcare reimbursement analysis and payment integrity. We have been voted one of 40 "Healthcare's Hottest" by Modern Healthcare and have been recognized by Inc. 5000 as one of the fastest growing companies in the United States.


The Director of Resolution and Appeals is responsible for supporting Company's Forensic Review findings, managing Company's Resolution and Appeals staff for the Forensic Review product, and managing Company's Complex Bill Review/high dollar claim negotiation staff. In addition, the Director of Resolution and Appeals oversees and guides innovations for new exceptions and opportunities for savings on the Forensic Review.


* Responsible for operation and management of CRR Resolution and Appeals Departments
* Supervise and manage Miami Complex Bill Review operations (liaison between CBR, Repricing division, Account Management and Sales)
* Corporate Subject Matter Expert (SME) on all aspects of Forensic Review findings
* Liaison with Operations teams for creating, reviewing and modifying Forensic Review and operational policies and procedures
* Develop innovations tracking and development plan to enhance Forensic Review savings
* Client education/implementation
* Manage and oversee both the Claim Resolution and Administrative Appeal teams
* Directly supervise and mentor Senior Manager, Resolution and Appeals
* Directly supervise and mentor Appeals Manager
* Directly supervise and mentor Sr. Resolution and Appeals Specialist/paralegal
* Indirectly supervise Claim Resolution Mangers
* Oversee development and maintenance of Appeals Response templates
* Oversee development and maintenance of Resolution correspondence and strategies
* Coordinate across departments to assure that Resolution and Appels responsibilities comply with client requirements/expectations.
* Manage and resolve escalated Appeals, Resolution and Litigation issues through the drafting of correspondence/pleadings and participation in conference calls, remote meetings and hearings as necessary
* Directly supervise Director of Clinical Bill Review Services
* Coordinate with Sales and Account Management Teams to assure that CBR role is developed and refined to successfully integrate with other Company products and maintain caseload necessary to meet revenue goals
* Address and resolve escalated client and claim challenges.


* Bachelor of Science in Nursing or Registered NurseLicense required
* Juris Doctorate or equivalent preferred
* Experience in healthcare claim adjudication, appeals, litigation and resolution
* Experience managing a team of 5 or more employees
* Ability to lead and operate a team and serve as a key member of the leadership team
* Effective organizational skills essential in the management of the resolution and appeals team and process
* Ability to multi-task and make decisions in order to successfully manage the team to meet tight deadlines and expectations
* Experience conducting targeted and complex legal and factual research regarding healthcare billing and compliance issues - state and federal law
* Experience drafting issue-driven adversarial business correspondence
* Experiencing analyzing, negotiating and resolving legal and factual issues regarding billing compliance, coverage limitation, In-Patient hospital payment and billing methodologies, and complex high dollar hospital billing disputes


A competitive salary is offered depending on experience and healthcare/insurance industry experience. Excellent benefits plan details will be provided to final candidates.