Clinical Appeals Manager – East Region (Remote) in Corporate at Alta Hospitals System

Date Posted: 9/15/2020

Job Snapshot

  • Employee Type:
    Full-Time
  • Location:
    3415 South Sepulveda Boulevard
    Corporate
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:
    9/15/2020
  • Job ID:
    16486

Job Description



Clinical Appeals Manager - East Region (Remote) 

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The East Region, Manager, Clinical Appeals is responsible for the management, administration, tracking and coordination of clinical denials/appeals for the comprehensive spectrum of inpatient and outpatient services for the region.  Evaluates and establishes an appeals process for all assigned Prospect Hospitals for clinical appeals/denials, payment retractions & underpayments.  Reviews and analyzes denial trends and recovery efforts from all payers and maintains oversight of external compliance physician advisor programs.  Reviews clinical audits as they occur and prepares appeals, as necessary.  Analyzes outcomes for identified Prospect hospitals and develops strategies to improve workflows and accomplish organizational goals and objectives.



Job Responsibilities/Duties

  • Manages the daily operations of the region, troubleshooting and resolving issues as they occur. Educates others on appeals/denials processes and guidelines on an ongoing basis.  Performs as a role model and consistently demonstrates an advanced level of expertise and enhanced communication skills. Keeps Revenue Cycle and Hospital leadership informed of region performance and escalates issues timely and appropriately.
  • Utilizes clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied.  Identifies risk factors, comorbidities and adverse events to determine if payer denial was justified and an appeal is required. Utilizes pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments.  Prepares convincing appeal arguments, using pre-existing payer criteria sets and/or clinical evidence from existing library of clinical references.
  • Performs duties in accordance with the ethical and legal compliance standards as set by hospital policies and procedures, and all regulatory agencies, including State and Federal. Maintains strictest confidentiality of protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
  • Works collaboratively with all departments including Accounts Payable, Medical Records, Billing, Financial Planning/Contracting, Business Office, Nursing and Out-patient Departments, Health Information Management, patient access, case management and financial services to resolve payment denials and documentation issues.   
  • Attends meetings and works closely with staff and Legal Counsel to review and coordinate team work product on high dollar claims for arbitration and legal escalation follow up.
  • Collaboratively works with technology and corporate denials leaders to develop and enhance automated denials team workflows and reporting activities.
  • Provides oversight of the team regarding clinical reviews/audits patient claims with medical necessity denials looking for patterns by services or by the ordering physician. Follow-ups in improving clinical documentation to reduce such denials. Works collaboratively with health information management coding staff, physicians, and financial services to resolve payment denials and documentation issues.
  • Effectively educates and mentors, and leads/participates in company initiatives, such as employee engagement, to support a team-oriented culture. Acts as a coach and positive role model for staff by establishing and maintaining a safe work environment that fosters positive morale.  Provides guidance and support to staff as needed.  Demonstrates behavior consistent with mission and core values.
  • Reviews data files from multiple sources, confirms accuracy and prepares scheduled and ad hoc reports on clinical appeals productivity, trends, facility specific denials activity and targeted prevention strategies.


Qualifications

Minimum Education:  Medical Graduate, Physician Assistant or Registered Nurse or other clinical science degree/experience.

Minimum Experience:  Five (5) years previous in one or more in case management/clinical appeals and denials management. Three (3) years overseeing staff and performing supervisor duties. Ability to multitask and maintain a work pace appropriate to workload. Must demonstrate customer service skills appropriate to the job. Excellent written and verbal communication skills in English. Ability to effectively communicate with staff, including physicians, in a clear and concise manner. Computer literacy and proficiency (EMR, Patient Financial Services Host system, Excel, PowerPoint, Word). Fluency in areas such as InterQual Level of Care Criteria and Milliman Criteria. Knowledge of third-party payer regulations preferred. Knowledge of clinical denials and case management working from the Payer’s perspective preferred.

Req. Certification/Licensure:  Physician Assistant or Registered Nurse



Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance


How to Apply

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www1.eeoc.gov/employers/poster.cfm

Keywords: Manager, PA, RN, Hospitals, Clinical Appeals, Appeals,  Case Management, Healthcare, Supervisor, Denials, EMR, Databases.



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