This position is responsible for the oversight of the retrospective denials management program for all payers, as well as related audits. This position provides leadership, direction and support in response to denials from federal, state and commercial reimbursement programs. This position is responsible for strategies which will minimize denials to ensure proper reimbursement for services provided by the organization, which includes auditing, managing, monitoring and reporting on trends and suggesting education to address specific processes, coding and billing regulations and prevent further claims denials.
Plans, directs and monitors the retrospective denials program for all payers (federal, state and commercial) across the organization. Directs and provides oversight to the centralized audit/denials team to ensure effective management of the company's response process. Provides advice, counsel, feedback and coordination that encourage a collegial relationship between staff, physicians and the leadership team.
Directs personnel actions including recruiting, new hire actions, interviewing and selection of new staff, salary determinations, training, and evaluations. This position also participates in the development of goals and objectives in accordance with company standards. Manage outside consultants involved in the appeals of the adverse audit determinations, as well as the clinical responses provided by the medical records audit/denials team, hospitals and external consultants.
Provides direction for multidisciplinary process improvement activities. This includes the development, implementation and evaluation of performance measures that will reduce retrospective denials across the organization and improve financial outcomes. Directs the collection, analysis and presentation of data for the retrospective denial management program. Provides reports to system and facility management on the impact of medical audit and denial activities and the effectiveness of responses including evaluating and reporting risk and potential exposure.
Oversees the development and implementation of strategies in cooperation with physicians, clinical staff and other employees to improve reimbursements and reduce retrospective denials as related to federal, state and commercial programs. Recommends changes to the workflow as necessary to best meet the needs of the organization. Suggests and coordinates education to address specific processes with regard to auditing, coding, case management and billing regulations to prevent further claims denials.
Receives all government medical record audit requests and retrospective denials and ensure proper entry and dissemination. Assures complete records and appeals are received by the appropriate appeals party in a timely manner by working with the medical records audit/denials team, facilities and external contracted experts.
Initiates and manages the appeal process with external experts, audit/denials management team and facilities in a timely manner. Tracks, monitors, trends and reports retrospective denial related recoupments and payments following appeals and the effectiveness of the appeal process. Determines the status and success of all appeals.
Keeps abreast of current changes with regard to audit trends that may affect health care systems. Ensures that up-to-date audit and retrospective denial strategies are in place across the organization.
Develops and oversees the department budget in conjunction with corporate goals and objectives. This position is accountable for meeting annual budgetary goals.
Requires a level of education as normally demonstrated by a Bachelors degree.
Requires proficiency typically obtained with five or more years working with hospitals and operations/clinical/finance. Must have considerable experience and knowledge in federal, state and commercial reimbursements typically acquired in 3 years auditing DRG coding and reimbursements. Must possess a working knowledge and understanding of healthcare-related government regulations, including Medicare and Medicaid billing, compliance and reimbursement regulations. Must be able to understand, apply and interpret complex billing rules in a variety of treatment settings and possess a thorough knowledge of medical coding and/or clinical practice in a complex care environment. Extensive knowledge of ICD-9-CM, CPT and DRG coding systems, LCD/NCDs, MAC/FIs required.
Extensive critical and analytical thinking skills required. Ability to organize workload, manage multiple projects, and maintain confidentiality of all work information. Must have highly developed leadership skills, interpersonal skills and the ability to work collaboratively in a matrix model as normally demonstrated through three or more years of professional and/or leadership experience.
Masters degree is preferred; Managed care experience is preferred.
Additional related education and/or experience preferred.
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.