Director, Home Health Grievances

Director Denials ManagementBecome a part of our caring community and help us put health first. The Director Denials Management provides leadership for the audit, appeal, and review process to preserve and recover revenue while maintaining the highest level of clinical and regulatory integrity and compliance. Manages the Denials Management data analytics, denial, and appeal process. The Director, Home Health Grievances & Appeals assists members, via phone or face to face, further/support quality related goals. Investigates and resolves member and practitioner issues. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes, and implements strategic plans, drives goals and objectives, and improves performance. Provides input into functions strategy.Responsibilities:Oversee the process for direction and support to clinical and operational leadership regarding Medicare and governmental audit trends, denials, and any CMS initiative and/or demonstration projects.Collaborates with leadership team in the development of an education plan to improve processes to preserve and recover revenue.Analyzes region-wide outcome indicators to measure achievement of quantitative and qualitative standards. Assists in the development, implementation, and analysis of internal and external benchmarking programs to measure the region's effectiveness in improving performance.Maintains region-wide Performance Improvement program which includes Customer Satisfaction, complaints, infection monitoring, Incident Reporting, and quarterly branch PI activity.Provides feedback and recommendations for changes to policies and processes, procedures and systems to enhance measures taken to improve performance.Communicate with Corporate leadership, Regional and Divisional leaders as appropriate to resolve issues that may place patients or the company at risk.Oversee educational in-services based on analysis of PI data and activities Acts as a resource for the Operations Support team and communicates Performance Improvement results.Participate in special projects and performs other duties as assigned.Use your skills to make an impactRequired Qualifications:Bachelor's degree in Nursing or related field10-15 years progressively responsible experience in home health or hospice industry that includes performance improvement and outcomes measurement5 years' experience in a supervisory or teaching roleThorough knowledge of health care policy, industry and related clinical practiceKnowledge in the interpretation and application of regulations and performance improvement standardsStrong Project management principles and clinical policy development/implementation requiredExpert knowledge of all Medicare regulations and appeals processesExcellent analytical skills with ability to interpret and apply regulatory requirementsExcellent verbal/written communication and presentation skillsAdvanced knowledge with Payer requirements, ADR requests, Denials, Appeals, RAC/ZPIC and CERT responsesMust be able to work well independently and in a team environmentExcellent communication and organization skillsStrong attention to detailHealthcare industry experience preferredMust read, write and speak fluent EnglishMust have good and regular attendanceApproximate percent of time required to travel: 30%Performs other related duties as assignedPreferred Qualifications:Master's Degree preferredLicenses/Certification: RN, PT or OT preferredMore than 3 years of grievance and appeals experienceStrong knowledge in Microsoft Access or experience with SQL Server databasesPrevious experience processing medical claimsBilingual (English and Spanish); with the ability to read, write, and speak English and SpanishScheduled Weekly Hours: 40Pay Range: $126,300 - $173,700 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.About us: About CenterWell Home Health: CenterWell Home Health specializes in personalized, comprehensive home care for patients managing a chronic condition or recovering from injury, illness, surgery or hospitalization. Our care teams include nurses, physical therapists, occupational therapists, speech-language pathologists, home health aides, and medical social workers all working together to help patients rehabilitate, recover and regain their independence so they can live healthier and happier lives.About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation's largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one.Equal Opportunity Employer: It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.