Manager, Clinical Denials

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Oversees the denial and appeal processes for the health system. Provides leadership to the clinical denial coordinators and assigned staff. Prioritizes, analyzes, and develops process improvement initiatives to reduce risk of revenue loss. Works in collaboration with the Clinical Financial Integration team to ensure appropriate revenue capture for the system.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. High School Diploma or Equivalent.

EXPERIENCE:

1. Five (5) years’ experience in healthcare accounts receivables management, billing and collections.

2. Three (3) years’ experience in healthcare denial management, with understanding of CPT codes.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s degree in Finance, Business Administration or related field.

2. Certified Healthcare Financial Professional (CHFP) with the Hospital Financial Management Association (HFMA).

EXPERIENCE:

1. Three (3) years of supervisory experience.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Leads the enterprise Clinical Denial Management program across hospital and physician practices ensuring alignment with organizational financial and compliance goals.

2. Maintains a clinical appeal process for outpatient denials assuring that proper documentation is provided to support appeals of services or denied for lack of documentation.

3. Maintains a clinical appeal process for outpatient denials, i.e., outpatient prior authorization denials, radiology denials, HMO denials for specialty care where a referral was not obtained and clinical documentation is required.

4. Oversee the clinical appeal process for physician denials, including, but not limited to, authorization denials, medical necessity denials or level of service denials.

5. Responsible for Adjustment work queues in EPIC for Tier 1 and Tier 2 requested Clinical Denial Adjustments and ensure accuracy and timeliness of request. 

6. Provides education and direction to Clinical Denial Staff for adjustments that are declined and further response is necessary to get the claim paid. 

7. Stays abreast of updates and changes to regulatory billing updates, regulatory requirements and organizational compliance policies to avoid audits and appeals/denials

8. Coordinates training, operations, and other activities for Denials Team. Supports Clinical Denial staff on a daily basis, keeping abreast of difficult/complex cases, and coaching, guiding as necessary.  Reviewing staffing ratios to ensure appropriate levels are maintained.

9. Provides feedback on process improvement activities and develops and presents focused educational programs for staff and physicians, both individually and in group settings.

10. Leads escalation of complex outpatient denials, partnering with Physician Advisors and fiscal attorney consultants, and works closely with them on development of second level appeals or moving to ALJ level.

11. Cross-Functional Authority: Acts as liaison for Legal, Patient Financial Services, Revenue Integrity, Audit and Training. 

12. Advices and assists with contacting and providing education to attending and physicians as needed to ensure documentation supports guidelines related to denial trending.

13. Collaborates in the ongoing re-design and re-engineering of Denial functions, to meet the changing needs and priorities of the organization.

14. Monitors payor portals for changes in reimbursement and/or billing guidelines and ensures that such data is uploaded to Wellington WI engine for appeal writing purposes. 

15. Facilitates training and education for clinical denial audit team for appeal writing process utilizing the AI engine in Wellington. 

16. Develops reporting mechanisms to monitor and report, productivity and outcomes for implementation and improvement strategies

17. Develops and maintains reporting dashboards to monitor denial trends, root cause analysis and financial impact. 

18. Facilitate monthly payer calls and team communications.   

19. Maintains Payer Grid by insurance provide for inpatient/outpatient submission with the payer representatives for both hospital and physician-based service lines. 

20. Maintains the Clinical Denial Teams Page, the Payer Handbook and annual updates 

21. Educates and serves as subject matter expert for the use of software programs that support Denial processes. Guides and assist I.T. partners with maintenance, development and upgrades of utilization management software; serving as content expert and communicating department needs.

22. Ensures compliance with state, federal, and contract payer rules, including Medicare Conditions of Participation.

23. Monitors productivity measures to ensure appropriate staffing are maintained to reduce denial write-offs.

24. Provides billing education to clinical members on appropriate measures to manage denials.

25. Works in collaboration with Clinical Financial Integration team to on-board new services and reduce over denial risks.

26. Reports any trending and process improvement initiatives to Director and key stakeholders.

27. Facilitates the timely process of all correspondence received from payers and routes appropriately. 

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

SKILLS AND ABILITIES:

1. Considerable knowledge of computers and the use/manipulation/application of data in support of administrative functions.

2. Knowledge of EPIC system is preferred.

3. Knowledge of Medicare, Medicaid and other regulatory requirements.

4. Knowledge of UB-04, itemized bills, insurance plans (i.e. Commercial Medicare, Medicaid, HMO, PPO, etc.) grievance procedures and utilization management processes required.

5. Knowledge of managed care, inpatient and outpatient care, utilization management, InterQual criteria.

6. Knowledge of the operations of patient billing is required.

7. Knowledge of medical terminology and the ability to interpret information in the medical record is required.

8. Knowledge of CPT, ICD9/10, and DRGs.

9. Effective organizational skills, attention to detail, ability to take initiative and excellent follow-through a must.

10. Ability to function as a team player and support of colleagues and staff is essential.

11. Ability to hold others accountable to performance related to lost revenue due to denials.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

661 SYSTEM Clinical Denial Management