Reimbursement & Appeals Supervisor
il y a 3 jours
Carlsbad
Exagen is a patient-focused and discovery-driven life sciences company dedicated to transforming the care continuum for patients suffering from debilitating and chronic autoimmune diseases. Our goal is to enable rheumatologists to improve care for patients through the differential diagnosis, prognosis, and monitoring of complex autoimmune and autoimmune-related diseases, including lupus and rheumatoid arthritis. By leveraging our proprietary Cell-Bound Complement Activation Products, or CB-CAPs, technology, we help get to the real cause of a patient's symptoms and guide their journey to improved health. The Reimbursement & Appeals Supervisor provides direct leadership for back-end revenue cycle operations focused on payer denials, appeals, reimbursement, and revenue recovery. This position oversees daily work distribution, staff performance, appeal quality and timeliness, payer follow-up, and resolution of complex reimbursement barriers. The Supervisor uses data, payer policy, and root-cause analysis to improve appeal outcomes, reduce preventable denials, and support accurate, timely reimbursement across commercial and government payers. This role is distinct from front-end billing supervision. Success requires demonstrated experience leading denial and appeal workflows, interpreting payer requirements, evaluating reimbursement outcomes, and translating trends into operational improvements. The Medical Biller Supervisor opening is a hybrid position that requires on-site work out of our Carlsbad office Monday, Wednesday, and Thursday, and candidates must live within commuting distance. • Oversee daily denial, appeal, payer follow-up, and reimbursement recovery activities, ensuring work is prioritized by filing deadline, appeal level, balance, aging, payer requirements, and likelihood of recovery., • Direct the review and resolution of complex denials, including medical necessity, coding, bundling, modifier, timely filing, documentation, and reimbursement-related denials., • Ensure appeals are accurate, complete, persuasive, supported by applicable records and payer policy, and submitted within contractual or regulatory timeframes., • Guide escalation through payer-specific reconsideration, external review, administrative, regulatory, and other dispute pathways when appropriate., • Monitor appeal inventory, aging, overturn rates, recovered revenue, upheld denials, write-offs, and unresolved payer issues., • Review underpayments and reimbursement variances; coordinate corrective action and payer escalation when payments do not align with applicable terms, policies, or expected reimbursement., • Maintain effective controls for appeal tracking, follow-up dates, correspondence, evidence, outcomes, and final account disposition., • Analyze denial and reimbursement data to identify recurring payer, process, documentation, coding, authorization, and system-related trends., • Perform root-cause analysis and develop measurable corrective action plans that address both recovery of affected claims and prevention of future denials., • Partner with front-end billing, coding, patient relations, provider support, market access, laboratory operations, finance, compliance, and technology teams to resolve upstream and downstream revenue cycle issues., • Recommend and implement sustainable workflow, system, worklist, reporting, and documentation improvements; avoid unnecessary manual workarounds when an electronic or automated solution is available., • Maintain current standard operating procedures, work instructions, appeal templates, payer reference materials, and escalation pathways., • Provide direct supervision, coaching, and development to assigned staff, including workload management, attendance, productivity, quality, professional conduct, and completion of assigned responsibilities., • Establish clear individual and team expectations, production standards, quality measures, and follow-up requirements aligned with departmental goals., • Conduct regular one-on-one meetings, team meetings, performance reviews, and documented coaching conversations., • Identify performance or behavioral concerns promptly and address them objectively and consistently in partnership with Human Resources and Revenue Cycle leadership., • Support Billing Leads and subject-matter experts in training, work review, quality audits, corrective action, and knowledge development., • Create a collaborative, accountable work environment in which employees are encouraged to raise concerns, propose solutions, and communicate barriers early., • Plan coverage, redistribute work as necessary, and respond to volume fluctuations, absences, payer deadlines, and urgent escalations., • Prepare and analyze weekly and monthly operational reports for Revenue Cycle leadership, including denial volume, denial rate, aging, appeal inventory, overturn rate, recovered revenue, productivity, quality, and payer-specific risk., • Use reporting to distinguish isolated errors from systemic issues and to identify responsible workflows, affected populations, financial exposure, and required corrective action., • Monitor accounts receivable and payer worklists to ensure timely, accurate follow-up and appropriate account resolution., • Communicate material trends, operational risks, payer issues, and recommended actions clearly to leadership and cross-functional stakeholders., • Participate in projects, audits, test launches, system implementations, and payer initiatives that affect reimbursement or denial risk., • Communicate effectively across in-person and virtual environments using Outlook, Microsoft Teams, Zoom, shared documents, spreadsheets, reporting tools, billing systems, and payer portals., • Select the appropriate communication channel based on urgency, complexity, audience, documentation needs, and required follow-up., • Facilitate meetings with clear objectives, decisions, owners, and due dates; ensure action items are documented and completed., • Handle escalated payer, provider, patient, and internal stakeholder concerns professionally, accurately, and within appropriate authority., • Build productive partnerships while maintaining accountability for deadlines, deliverables, and operational standards., • Ensure denial, appeal, reimbursement, and account resolution activities comply with applicable federal and state requirements, payer guidelines, contractual obligations, organizational policies, and privacy standards., • Remain current on payer policies, reimbursement requirements, appeal rights, coding and billing guidance, and relevant industry developments., • Ensure staff follow approved procedures and maintain complete, accurate, and audit-ready account documentation., • Identify compliance or quality concerns, escalate them appropriately, and implement corrective actions in partnership with leadership and Compliance., • Protect confidential patient, provider, employee, payer, and company information., • Two (2) or more years of direct supervisory or formal team leadership experience in a healthcare business office, revenue cycle, laboratory, hospital, physician, or similar payer-facing environment., • Five (5) or more years of progressive healthcare revenue cycle experience with substantial hands-on responsibility for back-end denials, appeals, payer follow-up, reimbursement, or revenue recovery., • Demonstrated experience managing multiple denial categories and appeal levels across commercial and government payers., • Working knowledge of payer policies, claim adjudication, medical necessity, authorization and referral requirements, coding-related denials, timely filing, reimbursement methodologies, and appeal documentation., • Experience using denial and reimbursement metrics to identify trends, quantify financial impact, develop corrective actions, and monitor results., • Demonstrated ability to coach employees, manage performance, establish accountability, and develop staff., • Strong analytical, critical-thinking, investigation, and problem-solving skills, with consistent attention to detail and follow-through., • Clear and professional written, verbal, listening, and presentation skills, including experience communicating with leaders and cross-functional stakeholders., • Advanced working knowledge of Microsoft Excel and comfort using Outlook, Microsoft Teams, Zoom, shared-document platforms, billing systems, reporting tools, and multiple payer portals., • Ability to organize competing priorities, meet payer deadlines, remain calm under pressure, and lead effectively in a high-volume environment., • Experience in laboratory, diagnostic, specialty, hospital, or physician revenue cycle operations., • Experience with Medicare, Medicare Advantage, Medicaid, TRICARE, Veterans Affairs or Community Care Network, and commercial payer appeals., • Experience with complex medical necessity appeals, external review, administrative escalation, regulatory complaints, or payer dispute resolution., • Knowledge of underpayment identification, reimbursement variance analysis, payer contracts, fee schedules, or reimbursement modeling., • Relevant certification in revenue cycle, healthcare finance, coding, billing, compliance, or leadership.
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