Appeals Manager, Department of Utilization Case Management

3 days ago


Bronx, New York, United States BronxCare Health System Full time

Job Summary:

The Appeals Manager, Department of Utilization Case Management will assist in the analysis and preparation of responses to payor denials and develop strong appeals for the purpose of securing reimbursement for acute care services provided to patients.

Responsibilities:

  • Establish and maintain positive relationships with patients, visitors, and other employees.
  • Contribute to and participate in the Performance/Quality Improvement activities of the assigned department.
  • Review and denial notification letters along with the medical records and all pertinent documentation related to the episode of care being denied in order to prepare a response for submission in appeal.
  • Identify and monitor for patterns and trends in denial activity by service and/or provider for the purpose of reporting and implementing corrective measures.
  • Provide feedback to UM staff related to denial prevention strategies.
  • Participate in JCAHO hospital wide preparation activities as designated by Director.
  • Conduct departmental performance improvement activities and monitoring on a quarterly basis and reports findings/analysis to Director.
  • Conduct educational/feedback sessions with UM staff related to PI activity findings and need for corrective action in order to improve outcomes.
  • Assist with preparation of quarterly reports for Bd. Of Trustees, Administration and Providers as needed.
  • Participate in special projects and committees as determined by Director.

Qualifications:

  • Registered Nurse or physician or a foreign medical graduate with ECFMG certification preferred.
  • Prior experience with reviewing medical charts in a medical office or hospital would be preferred.
  • Knowledge of Interqual / MCG guidelines will be a benefit.
  • Knowledgeable regarding CMS, JCAHO, IPRO standards, regulations, monitoring and reporting systems.
  • Knowledgeable regarding Regulatory Agency Mandates (State and Federal).
  • Excellent interpersonal, computer, verbal and written communication skills.
  • Ability to work independently as well as in teams for the purpose of advancing departmental goals and objectives of denial reduction.
  • Extensive Computer Knowledge.

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