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Director of Denial Management
4 weeks ago
About the Role:
The Director of Denial Management will lead and manage teams addressing non-clinical insurance carrier denials and underpayments. This role oversees vendor partnerships to create an efficient and effective denials and appeals workflow, optimizing revenue recovery. The Director collaborates across the organization to identify workflow and process improvements, sets goals, measures process effectiveness, and implements needed policies.
Key Responsibilities:
1. Collaborate with leadership, medical staff, and revenue cycle entities to ensure optimal reimbursement and regulatory compliance.
2. Lead multi-disciplinary work groups, chair denials management forums, and communicate denial trends to leadership, case management, and physician advisors.
3. Monitor and track meaningful metrics to assess performance of denials management workflows and validate KPIs and triggers process improvement efforts proactively based on performance targets.
4. Develop and manage initiatives to ensure denials management teams operate in line with organizational goals.
5. Oversee client denials prevention deliverables in partnership with internal and external business relationships. Consult with key stakeholders when issues arise, develop, and communicate action plans, and provide ongoing updates to all appropriate parties.
6. Partner with enterprise operations leaders, recommend, and implement changes to processes, tools, and/or methodology to ensure continuous improvement in operational efficiency and quality of services delivered while achieving operational budgets.
7. Interpret and implement complex rules and regulations governing insurance, appeal activities, trends, etc., to make recommendations.
8. Hire, orient, train, conduct performance evaluations, handle corrective actions, and provide a open and goal-oriented work environment with established clear and concise work procedures and productivity standards.
9. Manage successful recoveries of denied dollars from insurance carriers.
10. Work to minimize overtime expenses and maintain budget levels.
11. Demonstrate, through plans and actions, a consistent standard of excellence to which all departmental work is expected to conform.
12. Lead and/or participate in all performance improvement projects for the revenue cycle as assigned and identified.
Requirements:
Understanding of payer policies, procedures, NCDs, and LCDs. Proficient in payment review systems, hospital information systems, and coding methodologies. Strong quantitative, analytical, and organizational skills. Advanced understanding of an Explanation of Benefits (EOB). Intermediate knowledge of CPT, ICD-10, and HCPCS coding standards. Understand CMS Memos and Transmittals. Understand medical records, professional, and facility claims, and the Charge master. Knowledge of the content, structure, and maintenance of the charge master and fee schedules. Knowledge of various hospital and professional fee coding systems, including CPT, HCPCS, APC, ICD10, and DRGs. Utilize and understand computer technology. Understand all ancillary charges and multi-specialty departmental functions. Communicate orally and in written form. Understand insurance terms and payment methodologies. Work with physicians, administrative staff, and department directors effectively. Identify clerical error, mistakes in interpretation, imprecise records, and inaccurate service code assignment. Perform reviews for appropriateness of coding and charging, including business office activities, systems function, and charging methodologies.
Preferred Qualifications:
Strong understanding of the inter-relationships of the Revenue Cycle Departments. Strong understanding of Patient Financial Information System and Billing System. Certifications or credentials in EPIC Resolute HB, EPIC ADT Prelude, AAPC, AHIMA, and HFMA. 5+ years of applicable EPIC Revenue Cycle experience. Minimum of ten to fifteen years of progressive experience in appeal/denial management required. 15 or more years of leadership experience in a directly related role. 10 or more years of experience in billing, A/R follow-up. Successful achievement of the following: Illustrates autonomous, best revenue cycle practices. Illustrates proficiency in the use of all internal automation and software applications. Illustrates accuracy and consistency through Quality Review results of all audit documentation. Demonstrates ability to effectively manage multiple projects with innovation, creativity, and vision. Investigating and documenting any potential for new program and product development. Documenting results of all special project work and providing recommendations for revenue managing opportunities relating to special projects. Illustrating creative problem-solving skills through documentation of process improvement reporting and/or internal reporting mechanisms.
