Clinical Denials Manager

Overview

The Clinical Denials Manager at Riverside Healthcare is responsible for overseeing and managing the staff assigned to follow-up and collection of accounts, ensuring efficient resolution of claims and denials. This role includes developing and implementing information applications related to managed care contracts, providing end-user support, and maintaining the policy and procedure database for the department. The Clinical Denials Manager works closely with patients, customers, third-party payers, attorneys, and collection agencies to resolve billing and collection questions.

The role also involves identifying trends in denials, implementing solutions, and improving all system functions related to denials.

• Oversee and manage the staff responsible for the follow-up and resolution of claims and denials.
• Perform timekeeping duties for the department, ensuring accurate tracking of hours worked.
• Assist staff with high-level appeal documentation and provide guidance on complex denial cases.
• Develop, implement, and maintain the policy and procedure database for the department, ensuring up-to-date and effective guidelines for staff to follow.

• Work with patients, customers, and third-party payers to resolve billing and denial questions.
• Attend payer calls monthly, escalating issues related to denials as necessary.
• Identify trends in denials, evaluate potential resolutions, and implement corrective actions to minimize future denials.
• Send monthly audit information related to commercial and advantage audits as well as RAC (Recovery Audit Contractor) to the Director of Revenue Integrity.

• Maintain extensive knowledge of Medicare/Medicaid/DASA/HMO/PPO and miscellaneous billing requirements as defined by contract, state, or federal law.
• Prepare documents required by payers, internal and external auditors, ensuring compliance with regulatory standards.

• Work with outside attorneys and collections agencies to manage and resolve outstanding accounts.
• Implement solutions to improve the efficiency and effectiveness of the denials management process.

• Perform other patient accounts functions as needed to support the overall financial operations of the organization.
• Participate in special projects and initiatives as assigned by senior management.

• ICD9/CPT/Medical terminology preferred

• Three years of hospital revenue cycle experience within the last five years is preferred.
• Collection experience or insurance background is beneficial.
• Ability to work independently with minimal supervision.
• Excellent guest relations skills, including strong verbal and written communication abilities.
• Extensive knowledge of billing requirements across various payor types, including Medicare, Medicaid, DASA, HMO, PPO, and others.

• High school graduate or equivalent

Exposure/Sensory Requirements

Exposure to:

• Chemicals:
  Refer to MSDS manual
• Video Display Terminals:
  Average
• Blood and Body Fluids:
  Diagnostic composite of patients, frequent contact with intravenous devices, and high potential for contact with contaminated body fluids (blood, vomitus, stool) and administration of blood does create a high risk. Use of needleless IV system, universal precautions and protective equipment minimize risk..
• TB or Airborne Pathogens:
  Patient diagnostic presentations do pose high risk. Usage of protective wear and universal precautions minimize risk.

Sensory requirements (speech, vision, smell, hearing, touch):

• Speech:
  Required to communicate with patient/families/staff/doctors, coworkers, ancillary personnel and other department heads. Ability to ask for help.
• Vision:
  Required to perform necessary assessments of patient status, medication administration, CIS usage, and reading active orders and lab reports.
• Smell:
  Helpful to note presence of incontinence, vomitus, blood; electrical/fire safety.
• Hearing:
  Necessary to hear alarms, calls for help and to hear patient verbalizations. Necessary to…