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Description

PeaceHealth is seeking a Program Manager - Clinical Denials Procedures (Remote) for a Full Time, 1.00 FTE, Day position. The general salary range for this job opening at PeaceHealth is $49.85 – $74.78. The actual hiring rate is dependent upon several factors, including but not limited to, the job/position responsibilities, location, terms of the applicable collective bargaining agreement, education, training, work experience, seniority, work performance, etc.

Manages and facilitates appropriate utilization of health care services and assumes a leadership role with the interdisciplinary team to achieve optimal clinical and financial outcomes. Acts as an intermediary between hospital, third-party and government payors to ensure patients have appropriate medical services, and the organization receives appropriate and optimal reimbursement in accordance with contractual and regulatory requirements. The Program Manager, Clinical Denials/Procedural Specialist is responsible for denial avoidance strategies including concurrent payer communications to resolve status disputes, and pre-surgical/post-surgical review of patient status for accuracy. This position will also be responsible for reviewing and processing concurrent medical necessity denial through Peer-to-Peer or written appeal and developing processes to ensure appropriate pre and post status determination for surgical procedures.

*Must live in Oregon, Washington, Alaska or Texas*

Position Details:

• Accountable for the overall management of the Denial Management/Procedural UR program, working collaboratively with the Medical Director and Care Management Director.

• Develops, implements, and monitors evidence-based standards for denial management.

• Monitors contractual and government requirements for status determination of surgical cases and works closely with Physician Advisor to ensure appropriate status prior to surgery/procedure.

• Collaborates with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status.

• Analyzes and interprets denial data. Compares outcomes against program goals. Participates in creation of standards for data collection, feedback, and analysis.

• Ensures program compliance with mandatory regulatory requirements. Utilizes the concepts of Quality Improvement when planning and implementing process change.

• Analyzes recommended and regulatory best practice and assimilates the knowledge into clinical practice, assessing and communicating potential risk to revenue capture.

• Identifies issues and variations in utilization and escalates to appropriate members of the healthcare team. Actively supports measures that promote effective use of resources.

• Manages and responds to all concurrent and post-discharge third party payer denials of outpatient and inpatient cases alleged to be medically inappropriate. Schedules Peer-to-Peer as appropriate and creates written appeal letters when indicated.

• Internal expert for RN Case Management staff and others on documentation and reimbursement requirements. Serves as a resource to the health care team for utilization and denial management. Liaises with provider office staff and facilitates meetings with payers.

• Participates on the Utilization Review Committee to present medical necessity data and outcomes and partner with care management leadership to develop action plans for improvement.

• Oversees perioperative pre-authorization and patient class order reconciliation process.

• Facilitates and monitors adherence to the Medicare 2 midnight rule and the Medicare Inpatient-only procedure list.

• Performs other duties as assigned.

What you bring:

• Bachelor of Science in Nursing from an accredited school of nursing.

• MSN (or masters' degree in related field) preferred.

• Minimum of 3 year of Utilization Review required.

• Experience in surgery, emergency and/or critical care preferred.

• Strong statistical, data analysis, and clinical application experience preferred.

• Experience in process/quality improvement, quality measurement, data abstraction, data analysis and reporting, and data integrity preferred.

• Current Registered Nurse licensure.

• Specialty Certification preferred.

Skills

• Demonstrated competence in denial/appeals management and utilization management.

• Strong organizational and analytic skills.

• Highly effective written and verbal communication skills.

• Proficient with database management, spreadsheets, and word processing.

• Current knowledge of regulatory and accreditation requirements related to data review, quality measures, performance improvement and measurement systems.

• Knowledge of third-party reimbursement.

Department / Location Specific Notes

Working Conditions

Lifting

• Consistently operates computer and other office equipment.

• Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects.

• Sedentary work.

Environmental Conditions

• Predominantly operates in an office environment.

• Some time spent on site in medical/hospital setting.

Mental/Visual

• Ability to communicate and exchange accurate information.

• The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading.

PeaceHealth is committed to the overall wellbeing of our caregivers: physical, emotional, financial, social, and spiritual. We offer caregivers a competitive and comprehensive total rewards package. Some of the many benefits included in this package are full medical/dental/vision coverage; 403b retirement plan employer base and matching contributions; paid time off; employer-paid life and disability insurance with additional buyup coverage options; tuition and continuing education reimbursement; wellness benefits, and expanded EAP and mental health program.

See how PeaceHealth is committed to Inclusivity, Respect for Diversity and Cultural Humility (https://www.thecaregiver.org/wp-content/uploads/2017/05/PeaceHealth-Statement-of-Commitment-to-Diversity-and-Inclusion-vFINAL.pdf) .

For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state or federal laws.

PeaceHealth requires a completed Primary Vaccine Series (e.g., 2 dose monovalent Pfizer, Moderna or Novavax series or 1 dose J&J vaccine series) or be Up to Date (receiving the most recent Pfizer/Moderna bivalent vaccine/booster) for COVID-19 vaccination prior to their start date. PeaceHealth has a medical and religious exemption request process for those that are unable to receive the COVID-19 primary vaccine series due to medical/religious reasons. For caregivers that will be working in Oregon there is a personal vaccine exemption form that may be requested.

REQNUMBER: 66187