RWJBarnabas Health
Manager, Appeals
RWJBarnabas Health, Oceanport, New Jersey, us, 07757
RWJBarnabas Health - Manager, Appeals
Location: System Business Office, 2 Crescent Place, Oceanport, NJ 07757Job Overview:Our Denial Management Recovery Services division is an integral part of our company's success. The Manager of the Appeals team within the RWJ Barnabas healthcare facilities is responsible for managing clinical and technical denials and works to resolve the denials and authorizations.The Manager will collaborate with Case Management and Centralized Scheduling to ensure compliance pertaining to denial/appeal process with a focus on obtaining optimal reimbursement.This position will provide staff support to communicate with third-party payors to resolve discrepancies prior to billing. This position will also handle audit-related/compliance responsibilities and other administrative duties as required.Qualifications:Required:Must possess a valid nursing license (Current, valid RN/LPN/LVN licensure)Minimum of 5 years recent acute care experience with the last 2 years in a facility environmentMinimum of 2 years UR/Case Management experience within the last 2 yearsManaged care payor experience a plus either in Utilization Review, Case Management or AppealsFocused denials and appeals management experience requiredMust have excellent interpersonal, oral, and written communication skillsMust have excellent organizational and time management skillsStrong project management skills and advanced problem-solving and analytical skillsKnowledge in capturing, analyzing and communicating measurement resultsStrong Microsoft Office skills, particularly Microsoft ExcelAbility to work well individually and in a team environmentPreferred:Medical-surgical/critical care experience preferredEssential Functions:Manage the team, including analyzing WQ, QA of appeals, continued training, managing workflow and ensure denials are validated and appealed timely.Must have proficiency with online nationally recognized UM criteria, including Milliman Care Guidelines (MCG) and/or InterQual (IQ).Construct and document a succinct and fact-based clinical case to support appeal utilizing appropriate medical necessity criteria and other pertinent clinical facts.Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments.Demonstrate ability to critically think, problem solve and make independent decisions supporting workflow and appeal process.Maintain and organize the workflow to ensure that denials are worked according to departmental policy and standards.Create action plans, process improvement and address gaps and opportunities for improvement from front end to back end.Identify all denial trends and provide education of steps to prevent future avoidable denials.Validate denial reasons and ensure denial reasons are accurate and reflect the denial reasons codes.Generate an appeal based on the dispute reason and contract terms specific to the payer.Follow specific payer guidelines for appeals submission.Escalate exhausted appeal efforts for resolution.Research contract terms/interpretation and compile necessary supporting documentation for appeals adjudication issues.Work payer projects as directed.Develop and support effective working relationships among various departments for root cause analysis and resolutions.Review accounts and make recommendations to management regarding non-collectible accounts.Other Duties:Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.Additional Information:Benefits and Perks:Paid Time Off (PTO)Medical and Prescription Drug InsuranceDental and Vision InsuranceRetirement PlansShort & Long Term DisabilityTuition ReimbursementHealth Care/Dependent Care Flexible Spending AccountsWellness ProgramsVoluntary Benefits (e.g., Pet Insurance)Discounts Through our Partners such as NJ Devils, NJ PAC, Verizon, and more!RWJBarnabas Health is the premier health care destination providing patient-centered, high-quality academic medicine in a compassionate and equitable manner, while delivering a best-in-class work experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time.RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state.RWJBarnabas Health is an Equal Opportunity Employer.
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Location: System Business Office, 2 Crescent Place, Oceanport, NJ 07757Job Overview:Our Denial Management Recovery Services division is an integral part of our company's success. The Manager of the Appeals team within the RWJ Barnabas healthcare facilities is responsible for managing clinical and technical denials and works to resolve the denials and authorizations.The Manager will collaborate with Case Management and Centralized Scheduling to ensure compliance pertaining to denial/appeal process with a focus on obtaining optimal reimbursement.This position will provide staff support to communicate with third-party payors to resolve discrepancies prior to billing. This position will also handle audit-related/compliance responsibilities and other administrative duties as required.Qualifications:Required:Must possess a valid nursing license (Current, valid RN/LPN/LVN licensure)Minimum of 5 years recent acute care experience with the last 2 years in a facility environmentMinimum of 2 years UR/Case Management experience within the last 2 yearsManaged care payor experience a plus either in Utilization Review, Case Management or AppealsFocused denials and appeals management experience requiredMust have excellent interpersonal, oral, and written communication skillsMust have excellent organizational and time management skillsStrong project management skills and advanced problem-solving and analytical skillsKnowledge in capturing, analyzing and communicating measurement resultsStrong Microsoft Office skills, particularly Microsoft ExcelAbility to work well individually and in a team environmentPreferred:Medical-surgical/critical care experience preferredEssential Functions:Manage the team, including analyzing WQ, QA of appeals, continued training, managing workflow and ensure denials are validated and appealed timely.Must have proficiency with online nationally recognized UM criteria, including Milliman Care Guidelines (MCG) and/or InterQual (IQ).Construct and document a succinct and fact-based clinical case to support appeal utilizing appropriate medical necessity criteria and other pertinent clinical facts.Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments.Demonstrate ability to critically think, problem solve and make independent decisions supporting workflow and appeal process.Maintain and organize the workflow to ensure that denials are worked according to departmental policy and standards.Create action plans, process improvement and address gaps and opportunities for improvement from front end to back end.Identify all denial trends and provide education of steps to prevent future avoidable denials.Validate denial reasons and ensure denial reasons are accurate and reflect the denial reasons codes.Generate an appeal based on the dispute reason and contract terms specific to the payer.Follow specific payer guidelines for appeals submission.Escalate exhausted appeal efforts for resolution.Research contract terms/interpretation and compile necessary supporting documentation for appeals adjudication issues.Work payer projects as directed.Develop and support effective working relationships among various departments for root cause analysis and resolutions.Review accounts and make recommendations to management regarding non-collectible accounts.Other Duties:Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.Additional Information:Benefits and Perks:Paid Time Off (PTO)Medical and Prescription Drug InsuranceDental and Vision InsuranceRetirement PlansShort & Long Term DisabilityTuition ReimbursementHealth Care/Dependent Care Flexible Spending AccountsWellness ProgramsVoluntary Benefits (e.g., Pet Insurance)Discounts Through our Partners such as NJ Devils, NJ PAC, Verizon, and more!RWJBarnabas Health is the premier health care destination providing patient-centered, high-quality academic medicine in a compassionate and equitable manner, while delivering a best-in-class work experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time.RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state.RWJBarnabas Health is an Equal Opportunity Employer.
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