Manager of Clinical Appeals

Scope of Position

Revenue Cycle Clinical Support Office (RCCS) is an area within Access and Revenue Cycle Management Shared Services responsible for Clinical Pre-Certification, Case Reviews, Pre-billing edits, in-patient account validations, supporting Utilization Management, Peer to Peer processes, complex billing scenarios, audits (governmental, commercial, compliance, and internal), clinical appeals and denial management. RCCS is integral to the Revenue Cycle and supports cash collection through these various functions.

Position Summary

Responsible for daily operational management of Revenue Cycle Clinical Support staff, primarily involving the oversight of clinical appeals and denial analysis, resolution, and prevention for The Ohio State University Health System.

Implements and supports the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center. Functions within multidisciplinary teams. Leads staff on analysis and resolution of a variety of administrative and clinically related third-party payer denials and drives denial prevention efforts. The job duties require the utilization of clinical knowledge to interpret documented clinical information and apply medical necessity guidelines to determine appropriateness for services provided, including appropriate level of care (Inpatient or Observation). Is a Subject Matter Experts (SME) for commercial and governmental payer requirements and audits such as RAC, MAC, QIO, etc. Maintains an awareness of State and National Health care trends, JCAHO, CMS, and third-party payer policies and guidelines. Provides thorough support for the escalation of inappropriately denied claims to payers and external entities. Partners with Managed Care to seek resolution and appropriate reimbursement.

Is a SME and leads team members in understanding critical components of Scheduling, Financial Counseling, Pre-Certification, Admissions/Discharges/Transfers, Clinical workflows and documentation, Revenue Management, Charge Description Master, Coding (Diagnosis, HCPCS, Revenue Codes, Procedure Codes, Modifiers, etc.), Medical Information Management, Release of Information, Case Management, Utilization Management, Clinical Documentation Improvement, Compliance, Managed Care, Legal, Finance, Transplant workflows, Billing, Follow Up, Cash Posting, and any other areas that maybe needed to overturn and prevent denials. Guides staff on how to determine the strength of an appeal and author effective appeal letters. Also guides staff on understanding and interpreting the following and how they impact denials: payer remits and denial/remark codes, payer policies and manuals, and managed care contract terms. Responsible for analyzing accounts prior to adjustment to determine if all appropriate steps have been taken to obtain payment. Conducts quality assurance reviews and continuous process improvement on work done by staff and helps drive increase recoveries while maintaining lower AR.

Is highly independent, self-motivated, versatile, with strong communication skills. Is flexible and very adaptable to change given the frequent pace of change in health care and in revenue cycle. Follows direction from leadership and seeks to continuously exhaust the various avenues to overturn denials, increase recoveries, and reduce AR.

Develops and implements policies, procedures, workflows, and auditing procedures. Supports the incorporation of technology to facilitate and improve workflows. Serves as a resource on governmental regulatory interpretation. Significant involvement with physicians, physician leaders, administrators, and other departments.

Minimum Qualifications

For Hire Required:

* Bachelors degree in nursing with current license required, advanced degree preferred.

* Minimum of 5 years clinical care experience, caring for patients, anticipating their needs, and understanding the physicians plan of care.

* Minimum of 8 years denials and appeals experience.

* Five years of management experience in denials and appeals.

* Experience collaborating with physicians and their designees.

* Strong, proven analytical skills. Ability to make educated decisions.

* Extensive knowledge of clinical operations and patient flow.

* Skilled at synthesizing large volumes of information and concisely communicating either verbally or in writing.

* Proficient in Microsoft Office Products such as: Word, Power Point, Excel, SharePoint, Teams, OneNote, etc.

* Proficient in Adobe Professional Proficient in using email, fax machines, copy machines, internet browsers.

* Proficient at typing.

* Proficient in Technology, Computer, and Web applications. Must be able to multitask and move between applications quickly and frequently. Must be able to orientate self to new applications quickly. Must be able to manage complexities of having to work in multiple applications such as IHIS, MS Office products, 3M, and all payer websites/applications.