The Manager of Clinical Denials is responsible for the execution of operational and continuous improvement activities and achievement of expected performance in Clinical Denials Operations. Providing leadership and overseeing daily operations of the denials and underpayments functions for client. Functions under the responsibility of Denials Management include working with both internal departments and external departments / agencies in order to ensure that all charges for hospital services are timely and accurately paid through appealing and resolving denied accounts / charges. This leader is responsible for managing the client's Clinical Denials employees, relationships and performance management / reporting with 3rd Party Vendors who support client's Clinical Denials Management and reports to the Executive Director of Care Management

 

1. Five (5) years working knowledge of provider billing guidelines, payer reimbursement policies, and related industry based standards and healthcare managed care operations.

2. Three (3) years’ experience directly managing a team.

3. Experience and success in appealing clinical denials and underpayment decisions

4. Working knowledge and experience with InterQual and MCG standards.

5. Subject matter expertise and familiarity with Medicare and Medicaid requirements for encounters and full compliance.

6. Ability to examine financial, clinical denial and clinical data trends to reduce or eliminate denials that could potentially be avoided and establish appropriate prevention measure and action plans

 

Preferred Qualifications:

1. Direct management of the Clinical Denials Team ensuring front line capabilities to deliver seamless service outcomes from the claims process

2. Provide claim process expertise to create efficiencies and improve the clinical denials claims resolution process

3. Coordinate and communicate continuously with other departments to share information, best practices, systems issues, process solutions, and training needs 4. Manages reports / analytics / performance / relationships with client's external 3rd Party Vendors supporting Clinical Denial Management. Communicates results, insights, best practices solutions, and training needs

5. Lead, oversee, and manage the performance of the team as it relates to achieving denials and underpayments management and departmental productivity goals/targets.