Manager Clinical And DRG Denials

Overview

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

Under the direction of the Sr Manager Utilization Review, provides management for the denials management team. Responsible for day to day operations and overseeing the direction set by the Sr Manager. Oversight of the denials/appeals , underpayments, refund requests, and enhancing revenue through denials mitigation and denial management. Collaborates with multiple departments to ensure effective communication with Care Management, front-end UR, Coding, HIM, Payor Audit, Contracting, Physician Advisors and members of the business office. Manages staff responsible for the utilization management process to avoid unnecessary denials and maximize reimbursement for patients across Yale New Haven Health System. Responsible for the ongoing development and maintenance of internal controls surrounding departmental activities. Ensures efficient and accurate use of systems which support the operation and provides data for financial reporting. Analyzes data and makes recommendations to achieve optima results. Develops the staff to optimize their personal growth and contribution to the organization. Acts as the primary liaison between the Physician Advisors and the financial revenue cycle component for denials.

EEO/AA/Disability/Veteran

Responsibilities

• 1. Leads the denial team to utilize and optimize tools to ensure workflows are streamlined and new technologies are implemented to support operations.
  
  
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  2. Interacts with various levels of management and communicates with clarity.
  
  
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  3. Standing presence on the UR Committee and presents data as required.
  
  
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  4. Responsible for providing integrated data, reports and analyses relative to denials and monitors outcomes to effectively determine if System objectives are achieved.
  
  
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  5. Participates in departmental, interdepartmental and interdisciplinary committees which influence or recommends policies and or procedures affecting Utilization Review/denials management.
  
  
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  6. Collaborates with Business Office, Contracting, Coding Clinical Documentation Improvement and HIM management team and staff to support the most efficient work flow and to ensure that all financial requirements related to revenue recovery are met .
  
  
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  7. Provides recommendation to both Care Coordination and Utilization Review to avoid unnecessary denials and maximize reimbursement.
  
  
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  8. Investigates the potential to partner with external vendors to make strategic recommendations to improve efficiencies.
  
  
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  9. Develop, modify and oversee the internal FAX Concurrent Review Programs for the system to provide payers with the clinical information needed to make their certification decisions on a timely basis.
  
  
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  10. Oversee access to Epic Care Link (EC) for offsite RN users from payors and roll out additional payers.
  
  
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  11. Completes appeal audits and provides feedback on a monthly and as needed basis.
  
  
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  12. Enhance revenue and volume growth through payer satisfaction with service quality. Meet and interface with payers to ensure that mutual goals are addressed to everyone's satisfaction.
  
  
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  13. Evaluate payer denials and initiate appeals in an attempt to recover lost revenue. Address internal issues leading to payment denials with appropriate management and staff.
  
  
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  14. Track and trend resource utilization, LOS, ALOS, and adverse payment determinations, by payer, denial type, reason, rationale, physician, department, section, patient care unit, DRG, etc.
  
  
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  15. Collaborate with the Denial Reporting team to create summary and detailed reports so that adverse trends can be addressed both internally and externally.
  
  
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  16. Collaborate on strategies that differentiate patient care services on the basis of quality, cost and price, effectiveness and reimbursement.
  
  
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  17. Communicate with the contracting department to assist in drafting contract language to support the denials management process. Point of contact to escalate egregious denials.
  
  
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  18. Audit appeal letter quality and provide feedback and coaching to staff. Seek PA support to stronger clinical appeals. Track and report audit activity for the team.
  
  
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  19. Responsible to schedule staff, managing coverage, Kronos and Infor changes.
  
  
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  20. Create staff meeting agenda, schedule meetings and provide minutes.
  
  
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  21. Monitor and report out on KPIs.
  
  
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  22. In collaboration with Sr Manager, complete performance feedback, performance reviews, counseling and disciplinary action.
  
  
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  23. Responsible for documentation and tracking of key employee communications and feedback.
  
  
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  24. Assists with Infor and PILAT department and employee platform management including budget requests, employee objectives, learning management (LMS), and employee PTO.
  
  
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  25. Collaborates with other leaders on projects, initiatives and data reporting as needed.
  
  
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  26. Creates content for education sessions and presents it to the department.
  
  
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  27. Assists in the onboarding of new staff members including assisting with orientation, arranging for hospital issued equipment, and placing access requests.
  
  
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  28. Performs other functions necessary to ensure efficient operation of the department as required.
  
  

Qualifications

EDUCATION

Registered Nurse with current Connecticut License or MD. Bachelors Degree or MD required. Masters degree preferred. Coding/CDI credential preferred (CCS/CCDS)

EXPERIENCE

Minimum of five (5) years clinical experience and three (3) years of demonstrated leadership/supervisory/management experience required.

SPECIAL SKILLS

In addition to nursing background must have proven abilities in leadership, initiative and sound judgment with the ability to motivate others. Strong clinical knowledge is a must with the ability to lead discussions around clinical presentations. Problem-solving skills with demonstrated ability to successfully lead process change. Excellent organizational and communication skills with strong knowledge of patient reimbursement requirements and healthcare policies. Working knowledge of third party and prospective payment systems. Familiarity with ICD10-CM and CPT-4 Coding and DRG assignment. Demonstrated experience in data collection and analysis methods. Ability to manage and remain effective with multiple priorities. Knowledge of and proficient in the operation and use of computer-based information systems. Knowledgeable of Quality Improvement processes, and capable of implementing concepts. Ability to implement and support changes required. Ability to provide and meet the educational and competency needs of the defined function area.

YNHHS Requisition ID

120844