Appeals Manager, Department of Utilization Case Management Job at BronxCare Heal

Overview:

Assists in the analysis and preparation of responses to payor denials and develop strong appeals for the purpose of securing reimbursement for acute care services provided to patients. Assist in development of strategies for denial prevention based on identification of patterns and trends identified during the course of appeals preparation. Conduct departmental performance improvement audits, analyze findings and educate staff on variances found. Conduct JCAHO preparation activities to insure hospital wide compliance and readiness. Assist in the design and implementation of educational programs for Denial Prevention and Management.

Responsibilities:

- Establish and maintain positive relationships with patients, visitors, and other employees. Interacts professionally, courteously, and appropriately with patients, visitors and other employees. Behaves in a manner consistent with maintaining and furthering a positive public perception of Bronx-Lebanon Hospital Center and its employees.

- Contributes to and participates in the Performance/Quality Improvement activities of the assigned department. Contribution and participation includes data collection, analysis, implementation of and compliance with risk management and claims activities, support of and participation in Continuous Quality Improvement (CQI) teams, consistent adherence to the specific rules and regulations of the Bronx-Lebanon Hospital Center (a) Safety and Security Policies, (b) Risk Management: Incident and Occurrence Reporting, (c) Infection Control Policies and Procedures and (d) Patient and Customer Service.

- Reviews and denials notification letters along with the medical records and all pertinent documentation related to the episode of care being denied in order to prepare a response for submission in appeal.

- In absence of Director, will review denial correspondence to determine validity of denial reason and course of action to be taken.

- Maintains a working knowledge of InterQual Acute Level of Care Criteria in order to be able to apply to episode of care and utilize in the formulation of a strong appeal.

- Identifies and monitors for patterns and trends in denial activity by service and/or provider for the purpose of reporting and implementing corrective measures.

- Provide feedback to UM staff related to denial prevention strategies.

- Participates in JCAHO hospital wide preparation activities as designated by Director.

- Conducts departmental performance improvement activities and monitoring on a quarterly basis and reports findings/analysis to Director.

- Conducts educational/feedback sessions with UM staff related to PI activity findings and need for corrective action in order to improve outcomes.

- Maintains an excel log related to denials/appeals activities in order to monitor successful appeals.

- Assists with preparation of quarterly reports for Bd. Of Trustees, Administration and Providers as needed.

- Participates in special projects and committees as determined by Director.

Qualifications:

CERTIFICATION/LICENSURE : Registered Nurse or physician or a foreign medical graduate with ECFMG certification preferred . Prior experience with reviewing medical charts in a medical office or hospital would be preferred. Knowledge of Interqual / MCG guidelines will be a benefit.

- Knowledgeable regarding CMS, JCAHO, IPRO standards, regulations, monitoring and reporting systems.

- Knowledgeable regarding Regulatory Agency Mandates (State and Federal).

- Excellent interpersonal, computer, verbal and written communication skills.

- Ability to work independently as well as in teams for the purpose of advancing departmental goals and objectives of denial reduction.

- Extensive Computer Knowledge