Manager, Appeals & Denials – Direct Hire | Full-Time | Remote
Position Summary:
The Manager, Appeals and Denials is responsible for the day-to-day Appeals and Denials process by providing general oversight including leadership for the inpatient DRG/Coding Denials and Appeals process which includes tracking, prioritizing, trending and writing appeal letters, identifying training and educational opportunities as well as delivering training and education to CDI Appeals Specialists, Coders and DRG reviewers. The goal of the Manager, Appeals and Denials is to support the program by providing staff oversight, assisting with auditing and reporting, mentoring staff and strengthening client relations by providing quality appeal letters for the clients of Accuity.
This position collaborates with the Appeals and Denials Team, CDI Team, Appeals Medical Director, Coding, DRG Team as well as client healthcare team members to provide appeal letters that result in accurate, comprehensive documentation that reflects the true clinical picture of the patient. The appeal writer utilizes clinical expertise and clinical documentation improvement practices, current coding guidelines, state and federal regulations for ethical coding as well as facility specific tools for best practice and compliance with the mission/philosophy of Accuity.
Primary Job Responsibilities:
- Ensures compliance with external agencies as well as state and federal regulations for ethical coding
- Identifies and implements improvement measures that will enhance coding quality and client satisfaction
- Demonstrates appropriate knowledge and judgment regarding denials we received from clients
- Supports education of the remote and onsite coding staff and appeal writers
- Identifies and documents patterns, trends and variations in coding data and takes appropriate steps in collaboration with other departments to effect resolution or explanation of the variance
- Monitors the initiation, revision, and implementation of external regulations, statutes, and standards; facilitates implementation of revised regulations; ensures compliance
- Assists with chart audit and analyzes denial letters, makes recommendations for education, counseling or termination of staff as appropriate
- Review provisions for staff development, training and orientation prescribed by customers and any internal departmental standards
- Review denials received by client base, determines if denials are clinical or coding related, reviews the medical record as necessary to appropriately support appeal arguments, trends all data related to denials, develops and delivers training and education based on trends identified, and prioritizes all denials appropriately based on denial due dates, and Accuity due dates
- Assists with maintaining the integrity of data entry into Appeals and Denials tracking software
- Ensures adequate staffing for workload and steps in to assist teams when workload supersedes what the team can complete
- Reviews No Appeal letters to determine if appropriate, or if it can be appealed and provides Appeal Writer with feedback
- Assists Director Denials and Appeals Team with projects or tasks as assigned
- Performs miscellaneous job-related duties as assigned
Position Qualifications:
Education:
- Registered nurse or Coding degree or certification, or Degree in Healthcare (Management, Healthcare Administration, Health Information Management) or other related field(s) required
Experience:
- Minimum of 5 years appeals/denials or coding experience in the inpatient coding arena
- Minimum of 5 years of Management experience
Licensure and/or Credentials:
- CCDS and/or CDIP certification or RHIA, RHIT certification(s) preferred
Knowledge, Skills, and Abilities:
- Extensive knowledge of revenue cycle management and coding services
- Extensive operational knowledge of both physician and hospital revenue cycle
- Requires good interpersonal and customer service skills
- Demonstrated knowledge of ICD-10-CM, ICD-10-PCS, CPT, HCPCS, and modifiers
- Highly motivated and self-directed
- Analytical ability to gather and interpret data to identify areas of opportunity, problems, or issues and apply sound judgement
- Leadership skills that demonstrate accountability, decision-making, coaching and counseling
- Ability to interpret coding quality audit data, track and trend the results, and convert into applicable coding education
- Highly developed written and verbal skills
- Experience with electronic health records and health information systems
- Working knowledge of functional relationships between departments within a healthcare or similar environment
- Ability to organize and set priorities to ensure that objectives are met in a timely manner
- Ability to establish and maintain cooperative working relationships with physicians and staff
- Ability to oversee denial and appeals operation including but not limited to scheduling, work distribution, productivity monitoring, and quality output.
- Ability to use a PC in a Windows environment, including MS Word
- Independent, focused individual able to work remotely or on-site
Physical Requirements:
The requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job with or without reasonable accommodations.
Unless otherwise indicated, Accuity positions require interaction with people and technology while either sitting or standing. Employees must be able to communicate via phone, email, etc. and sit for extended periods of time, with or without reasonable accommodations. Physical effort and exposure to physical risk are limited to that of an office role environment.
While this job description is intended to be an accurate reflection of the job requirements, management reserves the right to modify, add or remove duties from a job and to assign other duties as necessary and at any time. All positions at Accuity are at-will employment, and a position description is not a guarantee of a job or of job responsibilities.