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The Manager, Home Health Grievances & Appeals manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if an a grievance, appeal or further request is warranted and then delivers final determination based on trained skillsets and/or partnerships with clinical and other Humana parties. The Manager, Home Health Grievances & Appeals works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals.

The Manager of Grievance and Appeals guides the overall audit, appeal and review process to preserve and recover revenue while maintaining the highest level of clinical and regulatory integrity and compliance. Provides direction and oversight to ensure appropriate and supportive documentation is submitted completely and efficiently and meets all regulatory and billing compliance. Uses clinical expertise to direct and guide agencies and staff through all selected CMS audits, initiatives and demonstration projects.

Essential Functions:

• Provide direction and support to the clinical and operational leadership regarding Medicare and governmental audit trends, denials, and any CMS initiative and/or demonstration projects.

• Collaborates with clinical and operational leadership in the development of an education plan to improve processes to preserve and recover revenue.

• Directs orientation for new staff both within the department and at the branch level (as needed) to assure audit, appeals and any medical record review process flows are within company standards.

• Monitors, trends and analyzes data to assist in developing plans to improve clinical documentation to ensure regulatory compliance to safeguard or recoup earned revenue.

• Directs workflow process and assignments to ensure all audits, appeals and reviews are submitted timely for preservation of revenue and/or reimbursement.

• Directs audit activity leads the development of appeal strategies and review responses.

• Directs the review of medical records and the various levels of appeals in preparation for and participation in Administrative Law Judge hearings. • Directs the regional managers to ensure audit, appeal and review processes are in place and effectively and efficiently implemented at the branch level.

• Directs the use of select EMR database information and the audit and denial management software.

• Directs the evaluation of agency readiness for all CMS audits and initiatives and guides the education at the agency level.

• Assist in promoting compliance with federal, state and local regulatory agencies.

• Protect the integrity of the organization, patients and co-workers by maintaining confidentiality of all patient and business information.

• Maintain and contribute to the efficiency of operations by consistently complying with all policies, procedures and guidelines of the company.

• Perform all job responsibilities with a friendly, positive and team-oriented attitude.

• Ensure compliance with all Company policies/procedures as related to Medicare billing practices and overall clinical operations.

• Participate in special projects and perform other duties as assigned

Use your skills to make an impact
 

Required Qualifications

• Thorough knowledge of health care policy, industry and related clinical practice
• Project management principles and clinical policy development/implementation
• Knowledge of all Medicare regulations and appeals processes
• Analytical skills with ability to interpret and apply regulatory requirements
• Excellent verbal/written communication and presentation skills
• Knowledge of Payer requirements, ADR requests, Denials, Appeals, RAC/ZPIC and CERT responses
• Must be able to work well independently and in a team environment
• Excellent communication and organizational skills
• Strong attention to detail
• Must read, write and speak fluent English.
• Must have good and regular attendance.
• Approximate percentage of time required to travel: 20%
• Performs other related duties as assigned.
• Bachelor or Associate degree in Nursing or Other Health Care related fields
• Professional License in current state of residence
• Minimum 5 years’ experience in health care management

Preferred Qualifications

• 10 years in Medical Certified home health care preferred
• Healthcare industry experience preferred

Additional Information

Travel: While this is a remote position, occ