Summary:

The Manager Denials Management reports to the Director of Claims Admin/Follow up. Under general direction and within Lifespan policies and procedures reviews denied claims and carries out the appeals process for the various Lifespan affiliates. Works to maintain third-party payer relationships including responding to inquires 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.

Responsibilities:
Executes the denial appeals process which includes receiving assessing documenting tracking responding to and/or resolving denials with third-party payers in a timely manner in conjunction with applicable internal departments.



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



Responsible for oversight of current policies and procedures related to written orders. Develops updates or revises policies and procedures related to written orders. 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 written order exception 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 Management 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.



Identifies improvement opportunities and contributes to the testing of system modifications works closely with all appropriate staff to ensure proper implementation



Integrates financial clinical and coding processes to improve compliance and maximize reimbursement



Sets up and maintains required records documents reports and correspondence specifications and other data related to studies and analyses.



Recruits selects orients evaluates and as necessary provides corrective action up to and including termination of denials management staff.



Perform other related duties as required.

Other information:
QUALIFICATIONS-EDUCATION:

Bachelors degree in Business Healthcare or related field.



Rhode Island State RN nursing licensure with active license.



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 6 FTEs.