Rev Cycle Accounts Receivable Manager

Job Summary

We are seeking a Revenue Cycle Audit and Appeals Manager to join our Revenue Cycle Team. We are a strong, dynamic and very efficient team that enjoys overcoming barriers to find solutions. We are adaptable and willing to take on a variety of tasks to improve operational efficiency for our internal and external customers, while functioning with a high degree of independence and minimal day-to-day supervision to deliver projects in a timely and effective manner.

Responsibilities

• Provide leadership in Revenue Cycle Hospital Billing Audit and Appeals by exercising professional knowledge and expertise regarding medical necessity review processes, payer authorization and benefit requirements, appeal criteria, and government regulation compliance.
• Design and implement operational objectives for the unit which consistently maintain high levels of efficiency and accuracy. Establish and monitor performance targets. Assure implementation of policies, procedures, and standards which support institutional and departmental objectives.
• Develop and foster a positive, collaborative, and value-driven culture within the unit.
• Ensure appeal letters are thorough, timely, and maximize the likelihood of a favorable outcome. Oversee usage of AI to support appeals process. Provide oversight and management of work queues, as well as resolution and escalation of issues. Develop management reports to guide decision making across units.
• Oversee interactions with third-party payers, peer-review organizations, and outside RAC, MAC or other Federal or State agents concerning denials and issues surrounding reimbursement for hospital services. Review, update, and implement policies consistent with CMS and other healthcare regulatory guidelines to ensure facility compliance and appropriate reimbursement.
• Select, develop, educate, evaluate, supervise and counsel Appeals Specialists and Appeals Supervisor. Responsible for all subordinate staff human resource activities including hiring, promotion, salary, performance coaching and disciplinary actions. Establish and maintain positive working relationships with payer representatives, internal customers, physician advisors, and other individuals. Develop and support routine, open and direct communications to resolve issues. Provide direction and oversight to staff in response to physician feedback on utilization, appeals and/or medical necessity concerns. Collaborate in development of responses to audits by State and Federal agencies.
• Review and evaluate outcomes of payer audits and initiate corrective actions as required. Provide direction and oversight to staff managing denial and appeal processes. Analyze root causes and initiate responses to minimize loss.

Required Qualifications

• A bachelor’s degree in business administration, Health Care Administration or related field, or an equivalent combination of education and experience is necessary.
• Prior experience in Utilization Management, Care Management or Hospital billing, or third-party claims adjudication and regulation.
• Experience with payer appeals and audits in a healthcare setting.
• The demonstrated ability to perform independently, with minimal supervision, and be able to work as a member of a team.
• Prior management experience.
• Knowledge of cross-departmental hospital and physician billing policies, third party payer processes and regulatory and accreditation requirements.
• Strong leadership skills with the ability to motivate direct reports.
• Strong interpersonal, presentation, and written communication skills, problem solving, decision making, and negotiation skills are necessary.
• Demonstrated the ability to work well with physicians and other health care providers.

Desired Qualifications

• At least 2-5 years of recent experience in Utilization Management, Appeals Management or Case Management.
• Current/active certification/licensing through professional association.
• Vast understanding of systems related to revenue cycle and health system billing, including but not limited to: MIChart/EPIC.
• Experience with initiating and developing policies and procedures to enhance revenue capture and margin enhancement including the ability to prepare projections, analyses and plans for operational improvement.
• Experience with initiating and developing policies and procedures to enhance revenue capture and margin enhancement including the ability to prepare projections, analyses and plans for operational improvement.
• Experience with initiating and developing policies and procedures to enhance revenue capture and margin enhancement including the ability to prepare projections, analyses and plans for operational improvement.