Director Clinical Denials

About the role

Oversees personnel involved in audit and clinical denials management to optimize customer experience and maximize reimbursement.

Responsibilities

• Provides leadership and support to staff responsible for managing denials and appeals processes.
• Develops and implements strategies to reduce clinical denials and improve reimbursement rates.
• Analyzes denial trends and identifies root causes to develop effective prevention strategies.
• Collaborates with other departments to ensure accurate and timely resolution of denials.
• Maintains policies and procedures related to denials management.
• Manages the budget and resources for the denials management team.
• Utilizes data analytics to identify areas for improvement and implement process enhancements.
• Communicates effectively with payers, providers, and other stakeholders to resolve denials and appeals.

Requirements

• Strong organizational skills [Required]
• Effective oral and written communication skills, with the ability to articulate complex information to all levels of colleagues [Required]
• Strong keyboard and 10 key skills [Required]
• Proficiency in Microsoft Suite applications, specifically Excel, PowerPoint, Word, and Outlook [Required]
• Ingenuity and judgment are required to review facts, plan work, estimate costs, interpret results, draw conclusions and take or recommend action [Required]
• A good understanding of payer requirements related to authorization and denial functions as well as reimbursement of all payers including but not limited to Government, Medicaid, Medicaid HMO products (i.e. VA, Tricare, Crimes Comp, Prisoners, etc.) and Managed Care / Commercial products [Required]
• Uses discretion when discussing personnel/patient related issues that are confidential in nature [Required]
• A comprehensive understanding of how Medicare DRG rates, Medicare APC rates, Medicare Fee Schedules, and Medicaid payments are calculated [Required]
• Demonstrated ability to be self-directed and work with minimal supervision/oversight [Required]
• Able to work in a project-oriented environment with people of various backgrounds [Required]
• Comfort with interpreting insurance contractual language [Preferred]
• Knowledge of InterQual and MCG as well as CMS LCD/NCD documentation [Preferred]
• Variety of clinical experience including nursing in ED, ICU/CCU, OB and/or nursing leadership position [Required]
• Basic knowledge of charge master systems [Required]
• Basic understanding and ability to navigate in DDE (online Medicare billing) [Required]
• Understanding of PFS registration and billing processes [Required]

Qualifications

• Bachelor's [Preferred]
• Bachelor's [Required]
• Master's [Preferred]
• Field Of Study (in Nursing, Business, Healthcare or Health Services Administration, Health Information Management, Communications, Finance, Accounting, Public Administration, Human Resources, Management, or Marketing)
• Medical Degree Secondary Bachelor’s Degree (in Business, Healthcare or Health Services Administration, Health Information Management, Communications, Finance, Accounting, Public Administration, Human Resources, Management, or Marketing) (in Nursing, Health Management, Business Administration, Finance, or other related area.)
• 3+ supervisory/managerial position in a similar-sized hospital [Required]
• 5+ related work experience in utilization review, care management, revenue integrity, denial management, or clinical documentation improvement [Required]

Skills

• Knowledge of InterQual and MCG as well as CMS LCD/NCD documentation [Preferred]
• Variety of clinical experience including nursing in ED, ICU/CCU, OB and/or nursing leadership position [Required]
• Basic knowledge of charge master systems [Required]
• Basic understanding and ability to navigate in DDE (online Medicare billing) [Required]
• Understanding of PFS registration and billing processes [Required]

Benefits

Includes medical, dental, vision insurance, life insurance, disability insurance, paid time off, 403-B retirement plan, whole person well-being resources, mental health resources and support, pet benefits, career development, and more.

Pay

$110,702.15 - $205,911.28

Schedule

Full time Shift Day (United States of America)