Manager - Rehab Authorization And Appeals - Greater Charlotte - FT

Job Summary

The Manager of Rehabilitation Authorization & Appeals plays a critical role in overseeing strategy and operations for both the Medicare Advantage authorizations and appeals and traditional commercial authorizations and appeals The Manager is responsible for developing and coordinating effective and efficient processes for appropriate and timely admission status determination based on regulatory and reimbursement requirements of various commercial and government payors. The Manager's expertise uniquely spans both clinical and administrative realms to provide crucial insight that maximizes appropriate patient access and preserves revenue opportunities. The Manager collaborates with leaders at various levels and specifically works closely with the Physician Advisor team within the organization to further the goals of increasing both appropriate patient access and revenue opportunities. Finally, the Manager is the main contact for coordinating external legal counsel support as it relates to patient advocacy and appeals at all levels, including ALJ hearings and the Medicare Appeals Council.

Responsibilities

• Responsible for the oversight of authorizations and denials at all levels (up to and including ALJ hearings) and increasing appropriate access to inpatient rehabilitation while maintaining revenue integrity. The goal is to transfer appropriate patients as quickly as possible while capturing compliant revenue for services received.

• Coordinate the total authorization, denials, and appeals program (both No Delay Auth and traditional auth) for Rehabilitation in the Southeast.

• Increase efficiency in identifying appropriate potential patients that will increase revenue for inpatient rehabilitation facilities throughout the Southeast while also improving throughput for acute care sites.

• Develop, coordinate, and maintain all appropriate data, dashboards, and outcomes related to KPIs for the entire project across the Southeast region.

• Facilitate communication between the Admissions, Business Development, Government/Commercial Payors Team, Physician Advisor Team, and executive leadership to communicate strategic success and opportunity.

• Coordinate with external legal teams to support the organization including, but not limited to maintenance and protected sharing of clinical and legal documents related to ongoing cases, appeals, and hearings, ensuring reliable and timely communication, and overseeing communication with ALJ offices.

• Improve equity in access to rehabilitative care across the organization by applying knowledge of Medicare regulations and patients' rights.

• Responsible for executive presentations and information sharing internally and at the national level for project outcomes as requested by Rehabilitation executives (i.e. AMRPA, etc.)

• Oversees authorization, denials, and appeals strategy development and implementation; monitors and maintains department specific related goals and objectives ensuring alignment with system strategy, vision, mission, and values.

• Ensures authorizations, denials, and appeals are documented with up-to-date standardized processes that have valid outcome measures monitored for compliance and improvement.

• Monitors the effectiveness/outcomes of Medicare Advantage authorizations and Commercial/Government payor authorizations by identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed.

• Leads and/or actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff.

• Maintains current and accurate knowledge of commercial and government payors and regulatory bodies related to authorizations and appeals.

• Promotes effective communication and collaboration among members of the organization as it pertains to rehab authorization and appeals and strategies for identifying potential appropriate referrals/admissions.

• Provides leadership, mentoring, and coaching to direct reports.

Job Requirements

Education

Clinical degree and MBA

Certification / License Physical therapy, occupational therapy, speech pathology, nursing or clinical social work issued by State licensing board and/or national board certification. Work Experience 5-7 years progressive healthcare experience. Knowledge / Skills / Abilities

• Knowledge and expertise in areas of authorizations and denial strategies, medical necessity, utilization management, and government relations

• Knowledge of reimbursement through Medicare Advantage, Government and Commercial payors

• Knowledge of appropriate reimbursement through all available appeal avenues (Level 1 Appeal, IRE Review, ALJ, Medicare Appeals Council, Post-Claim Regulatory Dispute, Post-Claim Contractual Dispute)

• Knowledge of appropriate clinical documentation as it relates to justifying the need for rehab

• Knowledge of clinical aspects (medical, functional, and social) of acute care and inpatient rehabilitation care as well as potential trajectory of improvement/rehab potential

• Knowledge of Clinical Liaison workflows, criteria for IRF services, appropriate regulatory and medical necessity framework for authorizations, and maximizing revenue capture for the related claims

• Knowledge of hospital systems as they relate to patient throughput, length of stay, and barriers to discharge

• Knowledge of accurate data gathering processes, basic data analysis, and data reporting.

• Knowledge of general health equity challenges

• Communication skills that allow for detailed explanations of complex ideas in writing and verbally

• Understanding of Medicare regulations and related laws governing authorizations, denials, appeals, and patients' rights

• Understanding of the prior authorization process for all payor classes

• Ability to review clinical documentation for medical necessity, rehab potential, and discharge planning in a timely manner

• Ability to effectively speak to patients, families, teammates, and external organizations with sensitivity to the level of communication that is most effective

• Ability to serve as a patient advocate for access to care

• Ability to effectively use the following: MS Excel, MS Word, MS Teams, MS Outlook, Adobe Acrobat, EMR (Epic)

• Ability to follow a standardized workflow while maintaining detailed documentation

• Excellent organization skills

• Ability to prioritize work according to deadlines

Physical Requirements and Working Conditions

Work requires walking, standing, lifting, reaching, bending, and stooping. Must lift a minimum of thirty-five pounds. Ability to travel/drive between various locations is required for this position. Requires frequent verbal and written communication in English. Must have intact sense of sight and hearing, finger dexterity, critical thinking, and ability to concentrate. Must be able to respond quickly to changes in assignments. Occasional intermittent noise and exposure to conditions such as dust, fumes, and chemicals.

Preferred Job Requirements

Education MHA preferred Certification / License - Experience Clinical practice in one of the above licensed/registered/certified disciplines, utilization management, discharge planning and appeals; inpatient rehabilitation hospital experienced preferred.

DISCLAIMER

All responsibilities and requirements are subject to possible modification to reasonably accommodate individuals with disabilities.

This job description in no way states or implies that these are the only responsibilities to be performed by an employee occupying this job or position. Employees must follow any other job-related instructions and perform any other job-related duties requested by their leaders.