Clinical Appeals Manager MN
Yonkers, New York • Grant Funded • Day shift, Monday–Friday, 8:30 AM–5:00 PM
About the role
This position directly manages the appeals process at the Wakefield Division of Montefiore Medical Center. The RN/PA/FMG/MD/HIM Professional responds to third-party clinical denials, interfaces with health plans, works closely with Finance and Contracting regarding utilization-management health-plan issues, and advises the Director of denial trends. They analyze Wakefield Division denials and act to minimize the financial impact of third-party payer denials, ensure proper documentation in the designated automated tracking application, and perform first-level review for FFS Medicare elective and emergent hospital admissions. The role also serves as a resource on medical necessity to department associates and interfacing departments, educates and mentors Case Managers/CTCCs on rules, mandates, and regulations related to denials and appeals, and clarifies clinical scenarios with Case Managers/CTCCs when medical-record documentation is insufficient. CTCCs performing appeals activity report to this associate.
Requirements
- Bachelor’s degree in health care or related field required; Master’s preferred
- RN, Physician Assistant, Foreign Medical Graduate, or HIM Professional preferred
- Analytical skills required
- Knowledge of medical terminology required
- Experience in Managed Care/Utilization Management required
- Excellent verbal and written communication and interpersonal skills
- Excellent organizational skills
Pay
$80,000.00–$100,000.00 per year