Clinical Appeals Nurse Manager

4 weeks ago

Oklahoma City, Oklahoma, United States Intermountain Health Full time

Job Description:

Full Time. Flexible shifts between 6:00 a.m. - 7:00 p.m. Monday-Friday.

The Clinical Audit & Appeals Nurse Manager is responsible for overseeing the clinical audit and/or appeals process for Intermountain Health. The manager leads a team of nurses who review medical records, conduct audits, and respond to appeals from payers, regulators, and other stakeholders. The manager ensures compliance with internal policies, external regulations, and contractual obligations, as well as quality and accuracy of audit and appeal outcomes.

Essential Functions

  • Develops and implements policies, procedures, and best practices for audit and appeal processes
  • Monitors and evaluates the performance and productivity of the audit and appeal team
  • Provides feedback, coaching, and training to the audit and appeal nurses
  • Ensures compliance with internal and external standards, regulations, and contracts
  • Coordinates and communicates with payers, regulators, in judicial proceedings and with other stakeholders regarding audit and appeal requests, findings, and resolutions
  • Analyzes audit and appeals data and trends and provides reports and recommendations to senior management. Partners with physician advisors to obtain clinical support for appeals
  • Identifies and resolve issues and challenges related to audit and appeal processes
  • Participate in quality improvement initiatives and projects
  • Maintain current knowledge of clinical standards, best practices, government and payer audits practices, industry trends, and billing compliance related topics. Partners with clinical areas and non-clinical areas affected by the changes in the industry.
  • Collaborates with Payer Contracting to ensure language within contracts best addresses clinical processes within Intermountain Health.

Skills

  • Medical Appeals
  • Content Expert
  • Leadership
  • Healthcare Billing
  • Clinical Knowledge
  • Communication
  • Data Analysis
  • Detail Oriented
  • Interpersonal skills
  • Problem Solving

Minimum Qualifications

  • Bachelor's degree in nursing (BSN) from an accredited institution required. Education is verified.
  • Current valid RN license required.
  • Demonstrated proficiency in computer skills including Microsoft Office, internet and email required.
  • Demonstrated ability to partner and build collaboration
  • Demonstrated ability to work effectively within a team environment.
  • Demonstrated mid-level experience in healthcare billing in a large, complex organization.
  • Demonstrated proficiency in analyzing data
  • Demonstrated expert level clinical knowledge.
  • Demonstrated ability to educate caregivers at all levels within the organization.
  • Demonstrated ability to present information clearly and concisely both verbally and in writing.

Preferred Qualifications

  • Master's degree in nursing (MSN)
  • Experience with Epic (EMR)

Physical Requirements:

Physical Requirements

  • Ongoing need for employee to see and read information, labels, documents, monitors, identify equipment and supplies, and be able to assess customer needs.
  • Frequent interactions with providers, colleagues, customers, patients/clients and visitors that require employee to verbally communicate as well as hear and understand spoken information, needs, and issues quickly and accurately.
  • Manual dexterity of hands and fingers to manipulate complex and delicate supplies and equipment with precision and accuracy. This includes frequent computer use for typing, accessing needed information, etc.
  • For roles requiring driving: Expected to drive a vehicle which requires sitting, seeing and reading signs, traffic signals, and other vehicles.

Anticipated job posting close date:

08/28/2024

Location:

Lake Park Building

Work City:

Work State:

Scheduled Weekly Hours:

40

The hourly range for this position is listed below. Actual hourly rate dependent upon experience.

We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.

Learn more about our comprehensive benefits packages for our Idaho, Nevada, and Utah based caregivers ) , and for our Colorado, Montana, and Kansas based caregivers ) ; and our commitment to diversity, equity, and inclusion ) .

Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.


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