Mgr, Denial Management

Job Description

ECU Health

About ECU Health Medical Center

ECU Health Medical Center, one of four academic medical centers in North Carolina, is the 974-bed flagship hospital for ECU Health and serves as the primary teaching hospital for The Brody School of Medicine at East Carolina University. ECU Health Medical Center has achieved Magnet® designation twice and provides acute and intermediate care, rehabilitation and outpatient health services to a 29-county region that is home to more than 1.4 million people.

Position Summary

The Manager is primarily responsible for assuring that clear lines of authority, communications and delineation of denial duties have been established and assigned with direction from the Director. The Manager will oversee all applicable denial job functions as stated in organizational and departmental policies and procedures. The Manager is responsible for researching, analyzing, resolving and trending rejections and/or denials specific to the revenue cycle. This includes, but is not limited to, analyzing specific denial categories and codes, researching the underlying reason for the denial, rectifying the issue in the denials management system and ensuring that the claim is adjudicated.

The Manager will provide educational programs related to non-clinical denial resolution techniques with the approval of the Director to stimulate growth within the department. The Manager is responsible for keeping informed of new changes in federal, state and third party regulations. Resolving ways to work within any new regulation with the approval of the Director as well as coordinating any testing or move to production efforts as it applies to denial resolution workflows. The Manager will also work closely with the Director to maintain appropriate files, reports and other statistical data as required and provide results of all special projects and provide recommendations for additional revenue opportunities. Coordinates re-bills and adjustments of accounts based on audit results.

The Manager will work closely with Managed Care Contracting/Underpayment department, Medical Records staff, and billing staff. The Manager will coordinate activities with other departments as approved by the Director and is expected to demonstrate, through plans and actions, that there is a consistent standard of excellence.

Responsibilities

1. Manage successful recoveries of denied dollars from insurance carriers;

2. Identify, research, mitigate and works with Director to resolve issues with revenue cycle billing related systems.

3. Works to minimize overtime expenses and maintain budget levels.

4. Reports denial trends and conducts root cause analysis to prevent future denials from occurring in relation to billing edits.

5. Demonstrate, through plans and actions, that there is a consistent standard of excellence to which all departmental work is expected to conform.

6. Lead and/or participate in all performance improvement projects for the revenue cycle as assigned and identified.

7. Serves as functional areas main contact with internal and external auditors

8. Coordinate and distribute work load to staff, provide training to staff, assist with employee orientation and formulate minutes of meetings and ongoing process.

9. Interviews, hires, trains, evaluates and develops subordinate management staff in accordance with defined policies and objectives.

10. Develops and recognizes staff through coaching, planning, training, appraising, and counseling.

Minimum Requirements

Associate degree and/or 10+ years related work experience required

10 or more years of experience in billing, A/R follow up, denials management & non-clinical appeal writing required.

10 or more years of leadership experience in a directly related role required

Bachelor's degree and/or 10+ years related work experience preferred.

Proficient in payment review systems, hospital information systems and coding methodologies.

Strong quantitative, analytical and organizational skills.

Advanced understanding of an Explanation of Benefits (EOB)

Intermediate knowledge of CPT, ICD-10, and HCPCS coding standards

Understand CMS Memos and Transmittals.

Understand medical records, professional and facility claims, and the Charge master.

Utilize and understand computer technology.

Understand all ancillary charges and multi-specialty departmental functions.

Communicate orally and in written form.

Understand insurance terms and payment methodologies.

Work with physicians, administrative staff, and department managers effectively.

Identify clerical error, mistakes in interpretation, imprecise records, and inaccurate service code assignment.

Perform reviews for appropriateness of coding and charging, including business office activities, systems function, and charging methodologies.


Additional Skill Set Requirement:

Strong Understanding of the inter-relationships of the Revenue Cycle Departments

Strong Understanding of Patient Financial Information System and Billing System


Performance Expectations:

Successful achievement of the following:

Illustrates autonomous, best revenue cycle practices;

Illustrates proficiency in the use of all internal automation and software applications.

Illustrates accuracy and consistency through Quality Review results of all audit documentation.

Demonstrates ability to effectively manage multiple projects with innovation, creativity and vision.

Investigating and documenting any potential for new program and product development.

Documenting results of all special project work, and providing recommendations for revenue managing opportunities relating to special projects.

Illustrating creative problem-solving skills through documentation of process improvement reporting and/or internal reporting mechanisms.

General Statement

It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.

Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.

We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.