Mgr Denials Management

SUMMARY: The Manager of Denial appeals reports to the Director of Claims Admin/Follow up. Under general direction and within Lifespan policies and procedures, manages and coordinates the review of denied claims and carries out the appeals and payer audit process for the various Lifespan affiliates. Assists and participates in the review and development of all levels of appeals. Develops and maintains current and accurate statistical data as it pertains to denied cases. Identifies and provides education on areas of documentation improvement with respect to level of care. Works to maintain third-party payer relationships, including responding to inquiries and other correspondence and possibly setting up arbitration between parties. Maintains and monitors integrity of the claim development and submission process as it relates to denial prevention. Brown University Health employees are expected to successfully role model the organization’s values of Compassion, Accountability, Respect and Excellence, as these values guide our everyday actions with patients, customers and one another. RESPONSIBILITIES:

• In collaboration with the Director, plans, implements and manages effective and efficient review and response to appeals. Ensures all appeals are filed within the time limits. Develops related policies and procedures and ensures implementation and adherence to same.

• Collaborates with Medical Director and Physician Advisors to apply uniform utilization standards.

• Collaborates with Contracting Department to develop fair, consistent and optimal reimbursement.

• Collaborates with the case management department and clinical documentation department on documentation that supports the level of care, severity of illness and risk of mortality.

• Systematically tracks the status and progress of denials and appeals for the Lifespan affiliates.

• Conducts relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms.

• Creates internal and external correspondence accurately, clearly, concisely and professionally while following organizational, federal and state regulations.

• Maintains data on the types of claims denied and root causes of denials, and collaborates with appropriate parties to make recommendations for improvements and resolving issues

• Develops and implements administrative procedures and review of current processes to enhance coding activities related to denials. Receives, reviews, and monitors progress reports from medical records, ancillary and other departments (using provider liable reports, medical necessity and ABN reports, un-coded accounts receivable reports, etc) related to denials appeals and takes the necessary steps to implement positive change.

• Provides clinical support to all members of the Denials and Clinical Appeal’s staff as well as other departments. Serves as a resource for clinical and coding information for many departments throughout the system. Reviews medical record information as needed.

• Coordinates and facilitates education programs for medical staff, department heads, managers and their staff with regards to denial prevention and proper appeal process.

• Works with departments involved to ensure understanding of Local Medical Review Policies and National Coverage Determination guidelines and the use of Advance Beneficiary Notices. Provides training and education to departments, physicians and their staff as needed regarding these issues.

• Recruits, selects, orients, evaluates and as necessary provides corrective action up to and including termination of denial appeals staff.

• Provides input into development of budget to meet anticipated needs.

• Maintains and enhances professional self-development by participating in appropriate workshops, conferences, and/or in-services.

• Perform other related duties as required.

WORK LOCATIONS/EXPECTIONS:

• After orientation at the Corporate facilities, work is performed based on the following options approved by management and with adherence to a signed telecommuting work agreement and Patient Financial Services Remote Access Policy and Procedure..

• · Full time schedule worked in office

• · Full time schedule worked in a dedicated space in the home

• · Part time schedule in office and in a dedicated space within the home

• Schedules must be approved in advance by management who will allow for flexibility that does not interfere with the ability to accomplish all job functions within the said schedule. Staff are required to participate in scheduled meetings and be available to management throughout their scheduled hours. Staff must be signed into Microsoft Teams during their entire shift and communicate with Supervisor as directed.

• PERFORMANCE STANDARDS:

• Effective utilization of resources

• Management of continuous quality improvement

• High quality, high value patient-focused services

• Resource productivity

• Fiscal responsibility

• Development and implementation of effective quality programs

• Customer satisfaction

• Performance improvements year-to-year

• Positive feedback from peers, directs reports and staff

MINIMUM QUALIFICATIONS: QUALIFICATIONS-EDUCATION:

• Bachelor’s degree in Business, Healthcare, or related field. Maintains Active RN nursing licensure in state of residence. Certification in billing and coding preferred.

QUALIFICATIONS-EXPERIENCE:

• Five to seven years progressively responsible experience in health care with heavy emphasis in one or more of the following areas: health services, administration, financial analysis, financial reporting, financial operations, departmental operations and managed care policies. Experience should demonstrate advanced numerical and analytical skills necessary to evaluate methods and systems utilizing statistical analysis, proficiency with PC based systems and high level of written and oral communications skills. Working knowledge of financial statements and ability to analyze financial information and determine financial impact of possible changes. Demonstrated knowledge of Hospital/professional billing and reimbursement, Medicare and Medicaid denials and appeals, Third Party Contracts, NCQA guidelines for denials and appeals. Federal and state regulations relating to denials and appeals and strong writing and communication skills.

SUPERVISION:

• Supervisory responsibility for up to 12 FTE’s.

Pay Range:

EEO Statement:

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

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