GENERAL SUMMARY: Under direction of the Senior Director of Denials-Appeals; provides leadership in implementing strategic initiatives related to the review of payment variance management, including the implementation of operational standards and integration of new technology to enhance processes, selection and implementation of trending analyses, assists in the development of standard escalation and education processes and policies, and assurance these initiatives meet company strategies. Provide management and oversight related to operational aspects of the payment variance department and supporting the hospitals in the netting down process. Oversees denial analysts, pre-denial analysts, and denial nurses.
AREAS OF RESPONSIBILITY:
- Denials
- Pre-Bill Denials
- Audit
- RAC
ESSENTIAL DUTIES:
- Work to identify and implement key management strategies related denial areas of responsibility.
- Manage Denial processes to identify, prioritize and provide oversight to ensure we are implementing consistent and comprehensive processes throughout the organization.
- Ensure processes identify trends by payor and across multiple hospitals to ensure most effective method of pursuit to include escalation through dispute resolution.
- Create and manage denial processes to ensure root causes are identified, corrected, and tracked to ensure accurate billing and timely collection of reimbursement.
- Create and manage process to handle denials are worked after being written off from AR once the first level appeal is upheld. Ensuring all levels of appeals are exhausted prior to formally closing the appeal process.
- Develop, implement and monitor key performance indicators to ensure that the payment variance teams are operating effectively.
- Monitor performance indicators to identify areas for best practice.
- Work with VP Revenue Cycle on any issues that cross the functional areas of responsibility.
- Provide management of technology solutions supporting operational areas of responsibility. Direct IT&S related to the payment variance departmental needs, development of ROI for system changes, prioritization and alignment of resources with needed enhancements related to all associated systems.
- Manage any new issues that arise related to changes in processes, payor contracts, changes in the company's portfolio, changes in the technologies being used by the departments, and any internal or external inquiries related to denial functions.
- Work with revenue cycle Executives to ensure that payment variance processes are meeting the needs of customers, the department and the Company.
- Lead the team through selection, implementation, and monitoring of vendors used to assist with Denial recovery efforts.
- Promote the department as a service organization and continuously help to identify and satisfy the needs of its customers.
- As needed, provide assistance to the VP of Revenue Cycle Operations in any area requested.
STANDARD QUALIFICATIONS
- Bachelor's degree required; master's degree preferred
- Minimum of five (5) years related experience in health care revenue cycle
- Three to five years leadership experience
- HFMA Certified Revenue Cycle Specialist preferred
Other Qualifications:
- Must be detail oriented and must possess excellent time management and organizational skills.
- Strong verbal and written communication skills.
- Proficiency in Excel, Word, PowerPoint and Access is necessary.
- Requires critical thinking skills, problem solving, decisive judgment, ability to work with minimal supervision and must possess excellent time management and organizational skills. Must be able to work in a stressful environment and take appropriate action.
- PC skills - demonstrated proficiency in Microsoft Office applications and others as requires.
- Policies and Procedures - demonstrates knowledge and understanding of organizational policies, procedures and systems.
- Basic skills - able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately.
- Technology skills - requires knowledge of computer systems, operating systems, networks and common software packages available to support database and spreadsheet applications. General knowledge of relevant system support and troubleshooting.
- Customer orientation - established and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations.
