Mgr, Clinical Denials Management

About the Organization

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally and grow spiritually by extending the healing ministry of Christ. You will be valued for your unique experiences and contribute to a purpose-minded team.

Benefits

• Medical, Dental, and Vision Insurance
• Life Insurance
• Disability Insurance
• Paid Time Off from Day One
• 403-B Retirement Plan
• 4 Weeks 100% Paid Parental Leave
• Career Development
• Whole Person Well-being Resources
• Mental Health Resources and Support
• Pet Benefits

Responsibilities

• Manages daily operations of the clinical denials management team
• Supervises, coaches, and develops clinical denial management specialists
• Monitors team performance against established metrics and productivity standards
• Reviews and approves clinical appeals for accuracy and quality
• Analyzes clinical denial trends and develops remediation strategies
• Collaborates with clinical leadership, physicians, and utilization management on denial prevention
• Coordinates with payers on complex clinical denial issues and escalations
• Ensures compliance with all regulatory requirements and policies
• Prepares and presents reports on clinical denial performance
• Participates in hiring, training, and performance management processes
• Identifies opportunities for process improvement and implements solutions
• Performs other duties as assigned

Requirements

• Strong knowledge of clinical documentation, medical terminology, and disease processes [Required]
• Comprehensive understanding of CPT, HCPCS, ICD coding systems, and clinical billing requirements [Required]
• Knowledge of payer policies, regulations, and clinical denial processes for government and commercial payers [Required]
• Understanding of utilization review criteria including MCG and InterQual [Required]
• Demonstrated leadership skills with ability to supervise and develop staff [Required]
• Strong analytical skills with ability to interpret data and identify trends [Required]
• Excellent written and verbal communication skills [Required]
• Proficiency in Microsoft Suite applications and healthcare information systems [Required]
• Ability to build collaborative relationships across departments [Required]
• Proficiency with Epic EHR system [Preferred]
• Experience with process improvement methodologies [Preferred]

Qualifications

• Bachelor’s of Nursing [Required]
• Master’s degree [Preferred]
• Field of Study: RN with Bachelor’s degree in Nursing, Management, or related healthcare field such as Healthcare Management, Risk Management, or Social Work; or RN with at least 5 years direct clinical experience, 8 years Utilization Management experience, demonstrated history of concurrent/post-remit denial management and avoidance experience
• 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)

Work Experience

• 2+ years in a supervisory/managerial position in a similar-sized hospital [Preferred]
• 4+ years related work experience in utilization review, care management, revenue integrity, denial management, clinical documentation improvement, or the Center for Medicare and Medicaid Services [Preferred]
• Varied clinical experience including nursing in ED, ICU/CCU, OB, and/or nursing administration positions such as Nurse Manager or Assistant Nurse Manager [Preferred]

Licenses and Certifications

• Accredited Case Manager (ACM) [Required]
• Registered Nurse (RN) [Required]
• Certified Case Manager (CCM) [Preferred]
• Certified Billing and Coding Specialist (CBCS) [Preferred]
• Registered Health Information Administrator (RHIA) [Preferred]
• Certified Revenue Cycle Rep (CRCR) [Preferred]

Physical Requirements

Please review the physical requirements for this role: Physical Requirements

Pay

$85,529.67 - $159,089.69

Schedule

• Full time
• Day shift

Location: 900 Hope Way, Altamonte Springs, Florida, 32714