Rn-Director Clinical Denials

Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will work alongside passionate and dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.

As the Director of Clinical Denials, you will initiate, influence, direct, and oversee the clinical resources supporting denial accounts receivable across the Cleveland Clinic Health System (CCHS). Your responsibilities include but are not limited to:

• Collaborating with pre-access, care management, physician advisors, market and network services and others to improve clinical documentation to prevent and successfully overturn denials.

• Educating Finance Case Managers, Coding Reimbursement Specialist, and Quality Nurses on commercial payer medical policies, governmental payer regulations, and inpatient criteria.

• Monitoring the performance of the clinical resources to ensure alignment to support department and organizational goals as well as compliance in coding and billing practices with regulatory requirements.

The Future Caregiver is someone who:

• Has High-level management and leadership skills.

• Can schedule and manage tasks effectively.

• Is experience with conflict resolution and problem-solving.

• Has written and verbal communication skills.

• Has teamwork and motivational skills.

This is a rewarding opportunity that offers growth-oriented projects, mentorship, support, and resources. You will experience great exposure to both the institute and department leadership and have numerous opportunities for career growth.

At Cleveland Clinic, we know what matters most. That's why we treat our caregivers as if they are our own family, and we are always creating ways to be there for you. Here, you'll find that we offer: resources to learn and grow, a fulfilling career for everyone, and comprehensive benefits that invest in your health, your physical and mental well-being and your future. When you join Cleveland Clinic, you'll be part of a supportive caregiver family that will be united in shared values and purpose to fulfill our promise of being the best place to receive care and the best place to work in healthcare.

Job Responsibilities:

• Initiates, influences, directs, and oversees the clinical denials accounts receivable activities to include personnel management, budget, productivity, quality, education and training, auditing, report management, appeal recoveries, performance improvement initiatives and developing standardized practices, processes, policies, and procedures across the CCHS enterprise.

• Promotes and helps maintain a professional team-oriented, service-conscious culture that contributes to the goals of the department and organization and reflects the values of the system.

• Other duties as assigned.

Education:

• Bachelor's degree in Nursing or Graduate of an accredited school of Nursing required.

Certifications:

• Current State Licensure as a Registered Nurse (RN) required.

Competencies (Complexity of Work):

• Advance knowledge of anatomy, physiology, medical terminology, pharmacology, pathophysiology, and disease process.

• Must have strong written, presentation, communication and verbal skills, excellent organization, and time management skills.

• Demonstrated excellent leadership, interpersonal, critical thinking, problem-solving and organizational skills.

• Must be able to work in a stressful environment and take appropriate action.

• Managing remote workforce preferred

Work Experience:

• A minimum of 7 years of experience in utilization review, clinical appeals and/or coding is required with an additional 2 years of experience of direct patient care in an acute med/surg, ICU, or ER setting.

• Experience with the electronic health records (EHR) required, Epic preferred.

• Experience with InterQual and Milliman disease management ideologies.

• Expertise in clinical appeal best practices, processes, and procedures.

• In-depth familiarity with third party billing requirement and regulations, billing documentation requirements. Understanding of CPT and HCPCS coding guidelines preferred.

• Knowledge and experience in process improvement methodologies and tools (e.g., LEAN) and clinical appeal documentation requirements.

• Advance knowledge of Microsoft Windows applications to include Word, Excel, Outlook, and PowerPoint and troubleshooting computer problems.

Physical Requirements:

• Ability to communicate and exchange accurate information.

• Ability to perform work in a stationary position for extended periods.

• Ability to work with physical records or operate a computer or other office equipment.

• In some locations, ability to travel throughout the hospital system.

• In some locations ability to move up to 25 lbs.

Personal Protective Equipment:

• Follows Standard Precautions using personal protective equipment as required for procedures.

Pay Range

Minimum hourly: $48.99

Maximum hourly: $74.71

The pay range displayed on this job posting reflects the anticipated range for new hires. While the pay range is displayed as an hourly rate, Cleveland Clinic recruiters will clarify whether the compensation is hourly or salary. A successful candidate's actual compensation will be determined after taking factors into consideration such as the candidate's work history, experience, skill set, and education. This is not inclusive of the value of Cleveland Clinic's benefits package, which includes among other benefits, healthcare/dental/vision and retirement.