Clinical Appeals Manager, Medical Plaza II

Primary Location:

Med Plaza II - UMC

Address:

250 E Liberty Louisville, KY 40202

Shift:

First Shift (United States of America)

Job Description Summary:

Manage team of 10-12 clinical reviewers and oversee Facility clinical claim denials by developing strategies to overturn insurance payor processing and proactively determine root cause and solutions to prevent denials for the UofL Health System. Clinical support will include pre-bill edits, payment denials, and pre/post-payment audits from insurance carriers or designated third party vendors as related issues such as medical necessity, experimental determinations, medically unlikely edits, non-covered services, and/or documentation. This position will collaborate with Revenue Cycle Leadership, Case Management and clinical service areas, Payor Relations and Contracting Department.

Job Description:

Position Summary and Purpose

Manage team of 10-12 clinical reviewers and oversee Facility clinical claim denials by developing strategies to overturn insurance payor processing and proactively determine root cause and solutions to prevent denials for the UofL Health System.  Clinical support will include pre-bill edits, payment denials, and pre/post-payment audits from insurance carriers or designated third party vendors as related issues such as medical necessity, experimental determinations, medically unlikely edits, non-covered services, and/or documentation.  This position will collaborate with Revenue Cycle Leadership, Case Management and clinical service areas, Payor Relations and Contracting Department.

Essential Functions:

Oversee clinical appeals team to ensure timely and quality denial resolution through development of policies, procedures, and training materials necessary to drive process improvement and staff performance.

Implement processes to track, trend, and reduce denials based on “root causes” across the organization with monthly reporting for Revenue Cycle leadership.

Collaborate with Care Management and HIM Coding managers on feedback for denials related to utilization management/coding as appropriate with escalation as needed.

Ensure Audit Recovery claims from Medicare/Medicaid or their vendor partners are received, tracked and appeals submitted timely.

Research commercial and governmental medical payor policies, regulations, and clinical abstracts related to claims payment to evaluate and appeal denied claims as well as preventing future denials.

Communicate effectively with providers and internal stakeholders to provide updates on denial trends and patterns so they can be efficiently shared to aid progression towards resolution.

Other Functions:

• Analyze medical records or other medical documentation to validate services, tests, supplies and drugs performed for accuracy related to the billed charges.
• Perform retrospective authorization requests for services already performed as needed.
• Establish denial prevention procedures in support of billing staff for targeted pre-bill edits for identified clinical issues.
• Support global denial prevention and mitigation efforts throughout the health system by attending denial prevention meetings and/or payor representative meetings.
• Communicate with physicians and multidisciplinary health system team members to effectively utilize all available resources to ensure strong and efficient appeals are submitted.
• Maintain compliance with all company policies, procedures, and standards of conduct.
• Perform other duties as assigned.

Job Requirements

(Education, Experience, Licensure and Certification)

Education:

• Bachelor’s degree in nursing (required).

Experience:

• 5 or more years of clinical experience (required).
• Experience with appeals and/or denial processing (preferred).
• Clinical nursing experience working in a hospital setting – ER, Critical Care, or Diagnostic Services (preferred).
• CCM (certified case manager), CPUM (certified professional in utilization management) or other relevant certification (preferred).

Licensure:

• Active, unrestricted registered clinical license (required).

Certification:

• CCM (certified case manager), CPUM (certified professional in utilization management) or other relevant certification (preferred).

Job Competency:

Knowledge, Skills, and Abilities critical to this role:

• Ability to review/comprehend and discuss Facility billing with Insurance or Government agencies.
• Knowledge of CPT/HCPCs, APCs, MS-DRGs, revenue codes, modifiers, and billing regulations.
• Experience working directly with Explanation of Benefits/Payments (EOBs/EOPs), contractual adjustments, and payer contracts.
• Organizational and documentation skills to ensure timely follow-up and accurate record keeping.
• Ability to think critically, work efficiently and responsibly in a collaborative environment with multiple work demands and brief time frames.
• Excellent leadership, communication, and organizational skills.

Language Ability:

• Must be able to communicate effectively in both verbal and written formats.

Reasoning Ability:

• Ability to read and interpret documents, i.e. contracts, claims, instructions, policies, and procedures in written (in English) form.
• Ability to define problems, collect data, and establish facts to execute sound financial decisions regarding patient account(s).
• Ability to analyze and interpret information on electronic remittances / EOBs / EOPs.
• Ability to analyze data, identify trends and implement improvements.

Computer Skills:

• Moderate to advanced computer proficiency including knowledge of MS Excel, Word and Outlook
• General computer knowledge and working with electronic filing systems.

Additional Responsibilities:

• Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times.

• Maintains confidentiality and protects sensitive data at all times.
• Adheres to organizational and department specific safety standards and guidelines.
• Works collaboratively and supports efforts of team members.
• Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community.

Additional Job Description:

UofL Health Core Expectation:

At UofL Health, we expect all our employees to live the values of honesty, integrity and compassion and demonstrate these values in their interactions with others and as they deliver excellent patient care by:

• Honoring and caring for the dignity of all persons in mind, body, and spirit

• Ensuring the highest quality of care for those we serve
• Working together as a team to achieve our goals
• Improving continuously by listening, and asking for and responding to feedback
• Seeking new and better ways to meet the needs of those we serve
• Using our resources wisely
• Understanding how each of our roles contributes to the success of UofL Health