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Salary: 83,343.00-125,034.00 USD

Facility: Administrative Regional Training Cntr

Shift: Shift 1

Status: Full Time FTE: 1.000000

Bargaining Unit: ACE Associates

Exempt from Overtime: Exempt: Yes

Work Schedule: Days

Hours:

M-F 8-4 with varied hours based on role of management and oversight of team

Summary:

The Clinical Denials and Appeals, Clinical Supervisor is responsible for the people, carrying out and documenting the appeals process for denied claims denied due to reasons including, but not limited to clinical documentation/support for diagnostic related grouping (DRG) assignment, inpatient and outpatient medical necessity. The individual also works to maintain third-party payer relationships. This includes, but is not limited to, responding to inquiries, complaints, and other correspondence, and may include setting up arbitration between parties. This individual provides clinical oversight to the clinical denials team, ensuring payer contracts are being appropriately followed by all parties, denials received are reviewed timely, investigated clinically for accuracy, responded to within required timeframes. The position acts as a liaison between front-end clinical areas and third-party payers in scenarios related to denials and appeals. This position educates all members of the patient care team on an ongoing basis in relation to trends in denials, and clinical documentation to influence behaviors to assist in the reduction of ongoing denials. This position is responsible for direct interaction and discussion of issues with both external parties (the payers) and internal stakeholders including, but not limited to, Utilization Review, Case Management, Clinical Documentation Integrity, Health Information Management, Physicians and Physician leadership, Finance, Information Technology and other Clinical stakeholders.

Responsibilities:

EDUCATION

+ Bachelor's degree with emphasis in healthcare administration, finance, business management, operational analysis, information systems or related field

+ Registered Nurse with a four (4) year degree and Unrestricted NYS RN license, preferred

+ Holds, or will obtain within one year of hire, one of the following (or similar) credentials: Certified Documentation Specialist, Certified Coder (CPC/CCS), Certified Processional Medical Auditor (CPMA), Certified Case Manager (CCM) or any other certification approved by management

+ Certification in a Nationally Recognized Utilization Review Criteria set is preferred

EXPERIENCE

+ Minimum of eight (8) years of experience working in an Acute Care Hospital Setting

+ Experience working within Utilization Review or Case Management or Clinical Documentation Integrity or

+ Experience in working with third party payers strongly preferred

+ Experience in working with people who are geographically dispersed

KNOWLEDGE, SKILL AND ABILITY

+ Ability to lead, challenge, motivate, coordinate and facilitate teams across the healthcare continuum

+ Excellent interpersonal communication and networking skills to develop positive, productive and collegial working relationships with multiple internal /external stakeholders across the continuum

+ Excellent critical thinking skills, Actively and skillfully conceptualizing, applying, analyzing, synthesizing or evaluating information gathered from or generated by, observation, experience, reflection, reasoning or communication as a guide to action

+ Knowledge of Quality Improvement, Root Cause Analysis, CMS and Joint Commission regulations

+ Fosters trust and exchange of ideas across departments to innovate and hardwire highly reliable practices

+ Ability and skill to create a learning environment and foster positive growth

+ Ability to manage in complex and demanding contractual relationships

+ Analytic skills for detailed reporting, creating dashboards and interpretation

+ Effective decision maker - able to gather facts, assess all perspectives and weigh different possibilities in order to influence positive outcomes

+ Adaptability - maintain effectiveness when experiencing major changes in work tasks or the work environment, able to adapt to change in environment and/or circumstances with a positive outlook and adjusting effectively to work within the new processes

+ Proactively prioritizes initiatives, effectively manages resources and keen ability to multi-task

+ Initiative - independently takes prompt proactive steps towards problem resolution

+ Facilitation - ability to facilitate small and large groups of people at various organizational levels for purposes of planning, problem solving, strategic development and policy changes

+ Excellent computer skills included but not limited to Microsoft Excel, PowerPoint and Word

WORKING CONDITIONS:

ENVIRONMENT

+ Office environment

+ Some local travel is required

REQNUMBER: 39256