Manager Clinical Denials - FT - Day - Revenue Integrity & Denials Mgmt Lawrenceville NJ

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range:

$94,140.80 - $122,990.40

Scheduled Weekly Hours:

40

Position Overview

SUMMARY (Basic Purpose of the Job)

Performs a variety of IP denials management activities to promote quality, clinical and cost-effective outcomes. Manages activities of assigned staff in the process of denials management and denials monitoring. Plans, assigns, reviews, and evaluates work delegated to staff. Monitors, reviews and assists to resolve denied claims. Follows denials process lifecycle until resolved to assure timeliness of response and identify appeal opportunities.

MINIMUM REQUIREMENTS

Education: High school diploma or equivalent. Associate degree preferred.

Experience: Five years' experience in denials management, appeals, and payors.

Other Credentials:

Knowledge and Skills: Excellent interpersonal, communication and negotiation skills with ability to convey understanding of complex issues. Strong organizational and time management skills. Strong leadership, motivational and team building skills. Analytical and data management skills. Knowledge of insurance and government payer guidelines.

Special Training: Proficient with Microsoft Word and Excel, and Outlook. Familiarity utilizing electronic medical record, utilization management software, and other patient information software.

Mental, Behavioral and Emotional Abilities:

Usual Work Day: 8 Hours  

Reporting Relationships

Does this position formally supervise employees? Yes

If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

ESSENTIAL FUNCTIONS

• Performs daily denials management functions, including communication with payers, utilization staff, revenue cycle, patient access and HIM.
• Oversees IP denials management staff to ensure appropriate processes are followed according to Capital Health policy.
• Assesses educational needs and provides department specific training and ongoing mentoring to denials management staff. Assures appropriate staffing levels, ongoing educational opportunities, employee satisfaction and customer satisfaction to maintain operational commitment.
• Conducts performance appraisals, manages reward and discipline process, addresses complaints, and resolves problems within the utilization review department.
• Maintains and organizes workflow to ensure denials are worked according to department policy and standards.
• Monitors turnaround times to ensure staff performance and tracks improvements towards department goals.
• Identifies concurrent and retrospective denial prevention opportunities. Identifies denial trends and provides recommendations to prevent or reduce avoidable denials.
• Ensures timely, accurate and efficient appeals for all medical necessity denials.
• Collaborates with leaders across the UR team to effectively problem solve and develop solutions to support department goals.
• Communicates with commercial and government payers to ensure IP reimbursement.
• Maintains and enhances relationships with internal and external customers.
• Identifies opportunities and takes a leadership role in departmental performance improvement activities.
• Assures established outcome measures are met, and continuous quality improvement approach is in place for all denials management staff.
• Performs other duties as assigned.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

Frequent physical demands include: Sitting , Standing , Walking , Carry objects , Wrist position deviation , Pinching/fine motor activities , Keyboard use/repetitive motion