Denials Manager

Company: Oklahoma Heart Hospital
Location: Oklahoma City
Posted on: September 10, 2023

Job Description:

Overview:
ONE TEAM. ALL HEART. At Oklahoma Heart Hospital (OHH), patient care is at the heart of everything we do. This physician owned hospital was designed by cardiologists to ensure that patients receive expert, individualized care with utmost comfort. OHH offers a competitive benefits program to all team members from the first day of employment.
Top Tier Benefit Packages:
Medical, Dental, and Vision
401 (k) plan
Paid Time Off (PTO)
Extended Medical Benefit (EMB)
OHH Financial Services: 7800 NW 85th Terrace, OKC OK 73132
Full-Time Days
Responsibilities:
Responsible for the overall management and communication of denials and appeals between Oklahoma Heart Hospital and outside payers. Responsible to function as a liaison and point to/for Medicare, Medicaid and third party representatives for denial and appeal inquiries. The Denials Manager will oversee a team of professionals, to include an RN and Denials Analyst. Follows up on the appeal and escalates as appropriate. Attends payer JOC calls and provides relevant trends, examples, and documentation. Reviews all potential readmissions, visits within 72-hours of admission, and payer recoupment requests. Manages the operational portion of RAC audits to ensure billing and collections are compliant. The Denials Manager will actively manage, maintain and communicate to appropriate stakeholders the denial and appeal trends and outcomes. Works with Director and key leaders to provide transparency and action plans to top denials preventing appropriate cash collections. Manages collections and reimbursement with appropriate documentation, placing optimal patient care at the forefront of all practices.
Review all denials by Medicare, Medicaid and third party payers to determine the viability of the appeal based on relevant inpatient guidelines or medical necessity requirements.
Draft appeals based on document inpatient criteria, DRG and coding guidelines, and contractual obligations.
Combine inpatient stays as medically appropriate.
Evaluate all readmissions and provide feedback on clinical outcomes for continuous process improvement.
Direct priorities and provide clinical consultation to appeals coordinators.
Adhere to all timely filing guidelines.
Work closely with Health Information Management, Case Management, and Compliance officer by maintaining timely oral and written communication. Manage, maintain and communicate to the appropriate stakeholders.
File first and second level appeals, and follow up on appropriate payment.
Review all payment recoupment requests from payers to validate legitimacy within clinical documentation; file appeals as necessary.
Qualifications:
Education: Bachelor's degree in healthcare, nursing, or business is required; Master's degree is preferred. A combination of education and experience may be considered for well-qualified candidates.
Experience: Minimum of three (3) years of leadership in revenue cycle, with experience in denials, appeals, utilization/case management, insurance follow-up, and authorizations. Working knowledge of bed management, utilization management, registration and patient demographics, cardiology procedures to include surgeries and devices, required. Foundational knowledge of medical billing and collections preferred. Must have a working knowledge of insurance reimbursement methods and authorization requires as defined by managed care contracts and national/local coverages. Epic experience is preferred but not required.
Licensure/Certification: CRCR certification is a plus but not required.
Working Knowledge: Excellent assessment, cognitive, and critical thinking skills a must. Makes complex decisions and acts in situations that are moderately to extremely difficult. Must be able to work independently to meet tight deadlines. Knowledgeable about the principles of continuous quality improvement and able to apply them. Strong analytical skills, including the ability to interpret and present information in a concise, meaningful way.
Interpersonal Skills: Must be able to effectively interact and communicate with adjacent departments, staff, physicians, and other hospital leaders.
Every team member at OHH plays an integral role in our patients' experience. They are the reason OHH continues to serve the state and lead the nation. Be part of the future of cardiac care.
Learn more about diversity at Oklahoma Heart Hospital.

Keywords: Oklahoma Heart Hospital, Oklahoma City , Denials Manager, Executive , Oklahoma City, Oklahoma