Medical Director Denial Management Nuvance Health

Nuvance Health has a network of convenient hospital and outpatient locations

• Danbury Hospital, New Milford Hospital, Norwalk Hospital and Sharon Hospital in Connecticut, and Northern Dutchess Hospital, Putnam Hospital Center and Vassar Brothers Medical Center in New York - plus multiple primary and specialty care physician practices locations, including The Heart Center, a leading provider of cardiology care. Non-acute care is offered through various affiliates,

Summary:

Management of Medical necessity Denials by root cause analysis and resolution for financial stability of the organization, provides a uniform structure, direction and education for optimum results and to achieve service excellence.

Responsibilities:

1.Oversee in patient Medical necessity Denials for the network by managing and supporting direct/indirect reports including RNs, Administrative Assistant, and per diem DM Physician Advisors

2.Review medical necessity denials to determine

a. Strength of documentation and criteria for appeal

i. If the case is viable,

b. Attempt peer to peer if timeline allows or send written appeal

i. if lacking, downgrade to a lower level of care

c. Adjust level of care (eg, NICU levels, ICU levels)

d. Adjust days

e. Combine readmissions

3.Write timely appeals based upon medical necessity using appropriate criteria (Milliman and/or InterQual , evidenced-based medicine for rationale and contracts.

4.Appeal medical necessity TPA denials and write brief memorandums for ALJ tp present the case before ALJ.

5.Maintain working relationship with payers via periodic discussions of medical necessity

6.Maintain working relationship with various departments

7.Implement CMS Form 1696 process to help mitigate MA medical necessity denials

a. Send beneficiary appeals

b. Send beneficiary grievances

8.Maintain contact with CHA via the Payer Audit Representatives Meeting

9.Periodically review CMS manual re: MA plans and keep up to date with national commercial and CMS denial issues

• RAC Relief, RAC summit, Modern Healthcare, Becker's, Medical Economics, Keckley Report, RAC Monitor, etc

10. Pursue/follow up with State Insurance Commissioner and/or AHA ie, compile issues.

11. Review of Medicare one-day length of stay cases for possible addendum (send to Assistant Hospitalist Director

• DH)/for NH, review with JK in CM and recommend possible addendum; otherwise possible adjustment to provider liable

12. Provide education to new Hospitalists upon employment re: UR processes (IP, OP, CC44), and DM processes (documentation, peer to peer and Yearly denial education to the Surgical

13. Comprehensive review QIO short stay denials, give oral presentation to rebut the denials, followed by written appeals to MAC, QIC, ALJ as needed

Other information:

• Minimum 5+ years of in-patient patient care experience

• MS Excel, Word, Presentation skills

• Knowledge base of Government (Federal/State) and Commercial payer policies, regulations, and contracts; knowledge base of medical necessity criteria;

• Board Certification and state licensure

• MD Degree / DO Degree accepted as well

• Experience in appeal writing and peer to peer discussions

• Ability to communicate effectively

Location: Summit-100 Reserve Rd

Work Type: Full-Time

Standard Hours: 40.00

FTE: 1.000000

Work Schedule: Day 8

Work Shift: 8-4:30

Org Unit: 1768

Department: Denial Mgmt

Exempt: Yes

Grade: P1

Salary Range:

Working conditions:

Essential:

• Significant manual skills / motor coord & finger dexterity

• Little or no potential for occupational risk

• Sedentary/light effort. May exert up to 10 lbs. force

• Generally pleasant working conditions.

EOE, including disability/vets.

We will endeavor to make a reasonable accommodation to the known physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation of our business. If you believe you require such assistance to complete this form or to participate in an interview, please contact Human Resources at 203-739-7330 (for reasonable accommodation requests only). Please provide all information requested to assure that you are considered for current or future opportunities.