At UMass Memorial Health Care, Everyone is a Caregiver regardless of title. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health care system of Central and Western Massachusetts, and a place where we can help you build the career you deserve. We are more than 14,000 employees, working together as one health care system. And everyone, in their own unique way, plays an important part, everyday.
Requisition #: 200593
Title: Director, Clinical Denial Management
Department: Hospital Billing Revenue Integrity
Posting Date: October 28, 2019
Location: UMass Memorial Health Care – 306 Belmont St, Worcester, MA
Oversees hospital clinical denial and appeal activity as well as clinical charge audit and Diagnosis Related Group (DRG) validation audit activity for UMass Memorial Health Care (UMMHC) system. Provides feedback to key clinical stakeholders to improve assignment of appropriate level of care, clinical documentation and accurate charge capture. Works in collaboration with Care Coordination department for denial reduction.
- Massachusetts Registered Nurse License.
- Bachelor's of Science in Nursing (BSN).
- Master's degree in related field.
Required: * Five - seven (5-7) years of experience in Case Management or Clinical Denial Review.
- Knowledge of CPT and ICD-10-CM coding.
- Previous experience in a managerial role, preferably in a healthcare environment.
- Thorough knowledge of HIPAA, Medicare and Medicaid regulations.
- Third party payer and billing system knowledge preferred.
Major Responsibilities: * Oversees hospital inpatient clinical denial management activity specifically in the area of level of care denials.
- Oversees RAC audits, Medicare suspense reviews, clinical charge validation audit and DRG validation audit activity for UMass Memorial Health Care (UMMHC) system.
- Communicates outcomes to corresponding UMMHC executive clinical leadership to prioritize areas of focus and support ongoing performance improvement, as required.
- Provides feedback to key clinical stakeholders to improve assignment of appropriate level of care.
- Identifies and addresses all corrective actions required as a result of denial review.
- Identifies and addresses all corrective actions required as a result of charge validation and DRG validation audits.
- Works with Director of HIM and CDI department to coordinate DRG validation activity and responses.
- Provides feedback to CDM Director for any Charge Master related issues identified through the audit process.
- Ensures timely appeal responses to all payers concerning hospital clinical denial activity.
- Assists the Physician Advisors and hospital billing team in the processing of third party appeals and negotiates potential problem cases with third party reviewers when applicable.
- Gathers and analyzes information from patient's medical record as relevant to audit activity.
- Prepares responses to denials by providing clinical justification and / or appropriate clinical setting to support the appeal process within the allotted timeframe as determined by the payer.
- Facilitates attending physician as well as Physician Advisor involvement in the appeal process.
- Manages the daily case work load to Clinical Denial Management Specialists and Hospital Auditors.
- Reviews denied cases as assigned and determines the appropriate setting for the patient's medical needs as documented in the medical record.
- Manages escalated cases from Clinical Denial Management Specialists that have not been resolved and brings to resolution.
- Provide routine performance statistics to Clinical Denial Management Specialists and direction as necessary.
- Coordinates all assigned denials and appeal activity.
- Monitors denial activity for trends and opportunities for improvement across UMMHC.
- Updates Managed Care Office of any concerns regarding trends where payer issues are identified.
- Assists the Hospital Billing Revenue Integrity Director to develop and execute target metrics and key performance indicators for UMMHC hospital entities to drive strategic analysis and decision making.
- Supports targeted revenue improvement opportunities and assists with analyzing the financial impact as related to clinical departments and revenue cycle areas.
- Promotes efficient inpatient denials and appeals management program for required corrective action.
- Provides timely clinical reviews to payers in compliance with contractual and regulatory agreements.
- Ensure regulatory billing updates, regulatory requirements, organizational and regulatory agency compliance polices are adhered to in an effort to avoid denials.
- Provides monthly denial activity report to the Utilization Management Committee across UMMHC.
- Directs and supervises assigned personnel including performance evaluations, scheduling, orientation and training.
- Makes recommendations on employee hires, transfers, promotions, salary changes, discipline, terminations and similar actions.
- Complies with established departmental policies, procedures, and objectives.
- Attends variety of meetings, conferences, seminars as required or directed.
- Demonstrates use of quality improvement in daily operations.
- Complies with all health and safety regulations and requirements.
- Performs other similar and related duties as required or directed.
- Works independently while contributing effectively to the accomplishment of team objectives and goals.
Standard Management Level Responsibilities:
- Directs and supervises assigned personnel including performance evaluations, scheduling, orientation, and training. Makes recommendations on employee hires, transfers, promotions, salary changes, discipline, terminations, and similar actions. Resolves grievances and other personnel problems within position responsibilities.
- Develops and recommends the budgets for the areas managed. Manages activities to assure financial goals are met.
- Coordinates the assignment of tasks and helps resolve technical and operational problems. Evaluates the impact of solutions to ensure goals are achieved.
- Provides effective direction, guidance, and leadership over the staff for effective teamwork and motivation and fosters the effective integration of efforts with system-wide initiatives.
- Encourages and supports diverse views and approaches, demonstrates Standards of Respect, and contributes to creating and maintaining an environment of professionalism, respect, tolerance, civility and acceptance toward all employees, patients and visitors.
- Integrates diversity into departmental objectives, such as hiring, promotions, training, vendor selections, etc.
- Participates in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
- Ensures compliance with regulatory agencies such as Joint Commission, DPH, etc. Develops and maintains procedures necessary to meet regulatory requirements.
- Ensures that department complies with hospital established policies, quality assurance programs, safety, and infection control policies and procedures.
- Ensures adequate equipment and supplies for department.
- Develops and maintains established departmental policies, procedures, and objectives.
- Ensures compliance to all health and safety regulations and requirements.
- Maintains, regular, reliable, and predictable attendance.
- Performs similar or related duties as required or directed.
All responsibilities are essential job functions.
We’re striving to make respect a part of everything we do at UMass Memorial – for our patients and for each other. We’re expecting that our new caregivers practice our six Standards of Respect: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player, and Be Kind, to help us make respect a part of how we take care of business everyday.
Job Type: Full-time