Appeals and Denials RN Manager

Appeals And Denials Nurse Manager

As Mount Sinai grows, so does our legacy in high-quality health care. Since 1949, Mount Sinai Medical Center has remained committed to providing access to its diverse community. In delivering an unmatched level of clinical expertise, our medical center is committed to recruiting and training top healthcare workers from across the country. We offer the latest in advanced medicine, technology, and comfort in 12 facilities across Miami-Dade (including our 674-bed main campus facility) and Monroe Counties, with 38 medical services, including cancer care, 24/7 emergency care, orthopedics, cardiovascular care, and more. Mount Sinai takes pride in being South Florida's largest private independent not-for-profit hospital, dedicated to continuing the training of the next generation of medical pioneers.

Our hardworking, tight-knit community of more than 4,000 dedicated employees fosters an environment of care and compassion. Each member plays a vital role in our collective mission to deliver excellent healthcare through innovation, education, and research. At Mount Sinai, we take pride in our achievements, aiming to be a beacon of quality healthcare in South Florida. We welcome all healthcare professionals to join our thriving community and contribute to our pursuit for clinical excellence.

Position Responsibilities

Management of Payor Processes and Relationships

• Develops and maintains effective relationships with payors, including contact as required with representatives from payors to ensure accomplishment of utilization management activities
• Oversees the management of observation cases, both concurrently and retrospectively, as needed.
• Supports the clinical denial management process, ensuring that all denials related to medical necessity and delays in service/discharge are identified and addressed promptly and documented appropriately
• Ensures concurrent flow of information between the Care Management Department and other MSMC departments responsible for managed care contracts and patient accounts/billing
• Participates with other MSMC entities who are involved in the denial management process to ensure that denials and appeals are tracked, trended, and reported to the Director regularly
• Is familiar with Payor policies and appeals processes and ensure appeals are completed and followed up on in a timely manner

Department Data and PI

• Generates and interprets reports/conducts audits to ensure compliance with documentation and to identify opportunities for improvement; follows up on any areas/individuals identified as having room for improvement
• Collaborates with other departments to generate outcome data as needed to measure and trend performance indicators identified in the Utilization/Medical Management Plan.
• Ensures the management of data collection, aggregation, and dissemination across the continuum, including: clinical, financial, and operational performance; this includes concurrent and retrospective medical record review

Staff Development

• Participates in hiring, reviews, discipline, and grievance handling to ensure optimal individual and team performance.
• Participates in staff development activities, interacting as needed with the director, customers, and others to continuously improve competency and effectiveness of the department.
• Identifies and addresses skills or behaviors requiring improvement, both at an individual level and at a department level.
• Provides coaching as needed to optimize performance and ensure safe and satisfactory care to patients and optimal customer service.

Other Departmental Functions

• Supports Director in development of department operational budget. Analyzes costs, identifies/develops strategies to ensure compliance with budgetary constraints and provides justifications for budget variances.
• Provides daily oversight and management to payor teams; Ensures that all of the functions of the staff are accomplished

Managerial Behavior and Development

• Engages in self-development in clinical, professional, and managerial areas; successfully completes leadership development curriculum.
• Adheres to standards, policies and procedures at both the hospital and Departmental level.
• Promotes a service orientation in the performance of position duties and responsibilities and in interactions with patients, hospital staff and visitors.

Qualifications

• Bachelor's Degree
• 5 years management or related experience

Benefits

We believe in the physical and mental well-being of our employees and are committed to offering comprehensive benefits that fit their personal needs. Our robust employee benefits package includes:

• Health benefits
• Life insurance
• Long-term disability coverage
• Healthcare spending accounts
• Retirement plan
• Paid time off
• Pet Insurance
• Tuition reimbursement
• Employee assistance program
• Wellness program
• On-site housing for selected positions and more!