Supervises and oversees the operations of the centralized appeals process for the Health System. Perform quality audits on appeal cases. Facilitates the even work-flow to maintain timely response to appeals.
Supervises, hires, trains, disciplines and evaluates the performance of staff.
Ensures performance appraisals on inpatient auditors are completed in a timely manner.
Provides training to new employees.
Performs monthly quality reviews on staff. Identifies, evaluates and implements opportunities for efficiencies.
Plans, organizes, coordinates and evaluates staffing requirements to meet operational goals.
Assigns and schedules direct reports to ensure smooth and efficient workflow.
Promotes staff development and education by providing opportunities for formal and informal education to promote competency.
Develops and performs staff educational programs. Ensures staff completes annual training.
Maintains data tracking systems and provides reports to Patient Accounts, Director of Case Management, Medical Director and Quality Management staff.
Sets performance standards and provides ongoing feedback to staff.
Generates department metrics.
Reports operational performance, justification and/or corrective action.
Oversees and coordinates appeals process.
Reviews and evaluates cases denied by all Third Party payers and determines follow through for level of appeals. Assigns cases to staff, as appropriate.
Monitors inpatient denials and assists patients and physicians with management of the appeals process.
Performs related duties, as required.
ADA Essential Functions
Bachelor's Degree in Nursing, required. Master's Degree, preferred.
Current license to practice as a Registered Professional Nurse in New York State.
Minimum of five (5) years clinical experience, plus a minimum of two (2) years experience in case management/utilization management/discharge planning and third party payment systems.
Maintains current knowledge of all IPRO, Managed Care and Third Party Review requirements.
In-depth knowledge of the appeals and denial processes; strong communications skills and computer literacy.