Dir, 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 Director of Denials Management is responsible for leading and managing the teams that addresses non-clinical insurance carriers denials and underpayments, as well as oversee the work of all associated vendor partnerships to create an efficient and effective denials and appeals workflow, and optimize revenue recovery. The Director works collaboratively across the organization to identify opportunities for workflow and process improvements, sets goals, measures process effectiveness and productivity, and implements needed policies.

The Director of Denial Management is responsible for directing and administering the operations, programs, and activities of a centralized non-clinical denial recovery operation, ensuring that processes and data meet regulatory requirements and policies. The Director will lead the planning and execution of strategic initiatives around technical (administrative) denials, payer relations, and professional/hospital site collaboration. Primarily responsible for assuring that clear lines of authority, communications and delineation of denial duties have been established and assigned.

The Director will work with the Denial Manager to provide educational programs related to non-clinical denial resolution techniques to stimulate growth within the department. The Director is responsible for keeping informed of new changes in federal, state and third-party regulations. Maintain appropriate files, reports and other statistical data as required and provide results of all special projects and provide recommendations for additional revenue opportunities. Work with the Billing Director to coordinates re-bills and adjustments of accounts based on audit results.

Responsibilities

1. Works collaboratively with leadership, medical staff, inter-disciplinary team members and revenue cycle entities to ensure optimal reimbursement and regulatory compliance.

2. Leads multi-disciplinary work groups, chairs denials management forums and communicates denial trends to Leadership, Case Management, and Physician Advisors

3. Monitors and tracks meaningful metrics to assess performance (effectiveness, efficiency) of denials management workflows and validates KPIs and triggers process improvement efforts pro-actively based on performance targets.

4. Develops and manages initiatives to ensure the operations of the denials management teams is in line with organizational goals.

5. Oversee client denials prevention deliverables in partnership with both internal and external business relationships. Consult with appropriate key stakeholders when issues arise, develop, and communicate action plans and provide ongoing updates to all appropriate parties.

6. Partner with enterprise operations leaders, recommend and implement changes to processes, tools and/or methodology to ensure continuous improvement in operational efficiency and quality of services being delivered while achieving operational budgets.

7. Interprets and implements complex rules and regulations governing insurance, appeal activities, trends, etc. to make recommendations.

8. Hires, orients, trains, conducts performance evaluations, handles corrective actions, and provides a open and goal-oriented work environment with established clear and concise work procedures and productivity standards

9. Manage successful recoveries of denied dollars from insurance carriers.

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

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

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

Minimum Requirements

Skill Set Requirement:

Understanding of payer policies, procedures, NCDs and LCDs

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.

Knowledge of the content, structure and maintenance of the charge master and fee schedules.

Knowledge of various hospital and professional fee coding systems including CPT, HCPCS, APC, ICD10 and DRGs

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 directors 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

Required Education/Course(s)/Training:

Bachelor's degree and/or 15+ years related work experience.

5 + years of applicable EPIC Revenue Cycle experience

Minimum of ten to fifteen years of progressive experience in appeal/denial management required.

15 or more years of leadership experience in a directly related role.

10 or more years of experience in billing, A/R follow-up

Preferred Education: Certifications or credentials in EPIC Resolute HB, EPIC ADT Prelude, AAPC, AHIMA and HFMA

Required Certification/Registration: None

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.