Mgr Cent Services Clinical Denial Mgmt

Description:

JOB PURPOSE:
The Manager of Clinical Denials is responsible for the execution of operational and continuous improvement activities and achievement of expected performance in Clinical Denials Operations.
Providing leadership and overseeing daily operations of the denials and underpayments functions for Piedmont Healthcare. Functions under the responsibility of Denials Management include working with both internal departments and external departments / agencies in order to ensure that all charges for hospital services are timely and accurately paid through appealing and resolving denied accounts / charges. This leader is responsible for managing the PHC Clinical Denials employees, relationships and performance management / reporting with 3rd Party Vendors who support PHC Clinical Denials Management and reports to the Executive Director of Care Management

MINIMUM EDUCATION REQUIRED:
Bachelors Degree in Business, Healthcare Management or related field.
MINIMUM EXPERIENCE REQUIRED:
Five (5) years working knowledge of provider billing guidelines, payer reimbursement policies, and related industry based standards and healthcare managed care operations. Three (3) years experience directly managing a team.
Experience and success in appealing clinical denials and underpayment decisions
MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
N/A.
ADDITIONAL QUALIFICATIONS:
Working knowledge and experience with InterQual and MCG standards. Subject matter expertise and familiarity with Medicare and Medicaid requirements for encounters and full compliance. Ability to examine financial, clinical denial and clinical data trends to reduce or eliminate denials that could potentially be avoided and establish appropriate prevention measure and action plans.

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