Job Purpose
The Vice President, Transformation Services- Denials Prevention is responsible for leading enterprise-wide transformation strategies that prevent avoidable denials, protect revenue yield, and drive top-tier revenue cycle performance across health system clients. This role uses analytics, payer intelligence, operational assessments, and root-cause analysis to identify revenue leakage and translate findings into actionable changes across the revenue cycle.
The VP partners with client executives and internal operational, clinical, and analytics teams to move the organization from reactive denial recovery to proactive prevention, ensuring interventions are implemented at the point in the revenue cycle where the denial originates. Success is measured through sustainable reductions in preventable denials and write-offs, improved first-pass payment and clean claim performance, increased net revenue yield, and achievement of top-tier performance benchmarks.
Duties and Responsibilities
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- Lead enterprise-wide denial prevention strategy and transformation across hospital revenue cycle operations.
- Identify and quantify opportunities to improve revenue yield by preventing avoidable revenue leakage before claims are submitted.
- Analyze denial, write-off, payer, and reimbursement data to identify root causes, emerging trends, and high-value transformation opportunities.
- Establish a comprehensive denial prevention framework that shifts organizational focus from denial recovery to upstream prevention and first-pass payment.
- Develop prioritized transformation strategies based on financial impact, preventability, payer trends, operational performance, and implementation feasibility.
- Drive performance toward top-tier industry benchmarks for initial denial rate, preventable denials, clean claim performance, denial write-offs, overturn rates, and first-pass payment.
- Lead root-cause initiatives across Patient Access, Prior Authorization, Utilization Management, CDI, Coding, Revenue Integrity, Billing, Clinical Operations, and Payer Management.
- Develop payer-specific prevention strategies addressing authorization, medical necessity, clinical validation, DRG downgrades, level of care, coding, timely filing, eligibility, and payment policy issues.
- Identify emerging payer behavior and policy changes and proactively develop mitigation strategies before they materially impact revenue.
- Partner with Managed Care and payer relations teams to identify systemic payer issues, contractual opportunities, and trends requiring payer escalation.
- Define and monitor leading and lagging KPIs that measure both denial outcomes and the effectiveness of upstream prevention strategies.
- Evaluate existing workflows and technology to identify opportunities to move edits and interventions earlier in the revenue cycle.
- Quantify transformation outcomes including net new revenue, avoided revenue leakage, cash acceleration, reduced write-offs, and cost-to-collect improvement.
- Partner with operational leaders to ensure transformation strategies are successfully implemented, adopted, measured, and sustained.
- Develop standardized denial prevention methodologies, playbooks, benchmarks, and best practices that can be deployed consistently across clients.
- Support client assessments, business development, and executive presentations by articulating denial prevention opportunities and expected financial value.
- Foster an environment of continuous improvement, accountability, data-driven decision-making, and proactive revenue protection.
Qualifications
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- 10 years of progressive leadership experience in Revenue Cycle Management and Denials work
- Bachelor's degree in Business Administration, Healthcare Administration, Finance, or a related field preferred
- Proven experience in a leadership role within revenue cycle services, preferably in a healthcare hospital-based healthcare setting
- Strong understanding of revenue cycle management principles and practices, with a demonstrated ability to deliver high-quality services to clients
- Possess knowledge of state and federal governmental, legal, and regulatory provisions related to front-end, middle and backend revenue cycle operations
- Excellent leadership skills, including the ability to motivate, mentor, and develop a high-performing team
- Proficiency in revenue cycle management systems, electronic health records (EHR), and client management tools
- Ability to adapt to a fast-paced and changing environment, managing multiple priorities and deadlines effectively
- Proficiency in Microsoft Office Suite
- Strong interpersonal skills, ability to communicate well at all levels of the organization
- Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
- High level of integrity and dependability with a strong sense of urgency and results oriented
- Excellent written and verbal communication skills required
Working Conditions
- Mustpossess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes.
- Physical Demands: While performing the duties of this job, the employee is required to move around the work area; light lifting required; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.
- Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.
- Work Environment: The noise level in the work environment is usually minimal.
Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.
