Mgr Denials Management

SUMMARY

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 everyday actions with patients, customers and colleagues.

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 adherence. 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 case management and clinical documentation departments on documentation that supports 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 recommend improvements and resolve issues. Develops and implements administrative procedures and reviews current processes to enhance coding activities related to denials; receives and reviews progress reports from medical records, ancillary and other departments and takes necessary steps to implement positive change. Provides clinical support to all members of the Denials and Clinical Appeals staff as well as other departments; serves as a resource for clinical and coding information and reviews medical record information as needed. Co‑ordinates and facilitates education programs for medical staff, department heads, managers and their staff regarding denial prevention and the proper appeal process. Works with departments to ensure understanding of local medical review policies, national coverage determination guidelines and use of Advance Beneficiary Notices; provides training and education as needed. Recruits, selects, orients, evaluates and, if 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. Performs other related duties as required.

WORK LOCATIONS / EXPECTATIONS

After orientation at the corporate facilities, work is performed based on approved options with a signed telecommuting work agreement and the Patient Financial Services Remote Access Policy and Procedure. Full‑time schedule worked in office. Full‑time schedule worked in a dedicated space at home. Part‑time schedule in office and in a dedicated space at home. Schedules must be approved in advance by management; staff are required to participate in scheduled meetings, be available to management throughout their scheduled hours, and stay signed into Microsoft Teams during the entire shift. Performance standards include effective utilization of resources, continuous quality improvement, high‑quality patient‑focused services, resource productivity, fiscal responsibility, development and implementation of effective quality programs, customer satisfaction, performance improvements year‑to‑year, and positive feedback from peers, direct reports and staff.

MINIMUM QUALIFICATIONS

Education: Bachelor’s degree in Business, Healthcare or related field; active RN nursing licensure in state of residence; certification in billing and coding preferred. Experience: Five to seven years of progressively responsible experience in health care with emphasis on health services, administration, financial analysis, financial reporting, financial operations, departmental operations and managed care policies. Demonstrated advanced numerical and analytical skills, proficiency with PC‑based systems, strong written and oral communication, working knowledge of financial statements, hospital/professional billing and reimbursement, Medicare and Medicaid denials and appeals, third‑party contracts, NCQA guidelines for denials and appeals, federal and state regulations, and strong writing and communication skills.

SUPERVISION

Supervisory responsibility for up to 12 FTE’s. Pay Range: $97,718.40 - $195,436.80 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. Location: Remote – Rhode Island – N/A Providence, Rhode Island 02901 Work Type: M‑F 8 to 5 Work Shift: Day Daily Hours: 8 hours Driving Required: No #J-18808-Ljbffr Brown University Health