NYU Winthrop is a 591-bed university-affiliated medical center, which offers sophisticated diagnostic and therapeutic care in virtually every specialty and subspecialty of medicine and surgery. We are a major regional healthcare resource with a deep commitment to medical education and research, offering a full complement of inpatient and outpatient services.
We have an exciting opportunity to join our team as a Director, Clinical Denials and Appeals.
In this role, the successful candidate Responsible for the management and coordination of the Clinical Denials and Appeals Process and Specialists. This includes assisting in the overall planning, organization and direction of the daily work assignments for the preparation of Clinical Appeals based upon evidence based criteria documented within the medical record. Conducts analysis on Clinical Denials and Appeals, identifying and presenting both Documentation Improvement and Revenue Protection opportunities. Serves as a subject matter expert while staying up to date on clinical regulations affecting Denial Prevention and Management practice. Provides Orientation, Training and Education to Clinical Denials and Appeals staff. Develops and collaborates with Physicians, Physician Advisors, and Clinical Service Line Leads for education and compliance. Participates in enterprise and hospital based meetings as needed.
- Develops and implements Standards of Practice for the Clinical Denials and Appeals Specialists as it relates to formulating and submitting responses to Clinical Denials from Commercial Payors, Managed Care and Third Party Review Organizations.
- Manages and prioritizes timely review, investigation and response to Clinical Denials and the required actions for appeals within contractual timeframes.
- Conducts ongoing education of Clinical Denials and Appeals Specialists as it relates to analysis of adverse determinations, knowledge and application of Interqual or Milliman criteria, timely review and response to payor denials, and maintenance of department metrics.
- Coordinates and collaborates with Content Experts across the enterprise (Physicians, Physician Advisors, Clinical Service Lines, Case Management, Health Information Management, Clinical Documentation Improvement, Inpatient and Outpatient Revenue Services, etc) as needed to obtain necessary documentation to support clinical appeals and implement prevention.
- Assists with the development, maintenance, and management of cases utilizing an internal tracking tool for the distribution of reports as requested by Leadership.
- Identifies, monitors and presents monthly denial performance trends utilizing case studies with recommendations for Process Improvements at Enterprise Wide Forums.
- Identifies potential risk for loss reimbursement related to medical policies and prior authorization requirements; escalates potential issues to clinical stakeholders, managed care, and revenue cycle leadership, as appropriate.
- Maintains expertise in clinical validation, reimbursement methodologies, and utilization management specialty areas by participating in professional organizations, seminars and educational programs.
- Provides orientation, training, and education to Clinical Denials and Appeals staff and participates in hospital-wide forums as needed.
- Performs other duties as assigned.
To qualify you must have a Bachelors Degree in Nursing or other Clinical Practice field. 5-7 years of Clinical RN experience including 5 years in Denial Management, Case Management, or related experience and 3 years of current experience with reimbursement methodologies.
Current and valid NYS Registered Nursing License
Experience with Interqual and or Milliman Disease Management Ideologies
Strong communication (verbal and written) and interpersonal skills
Ability to communicate with multiple levels of the organization: Senior Leadership, Physicians, Directors, Clinical and Support Staff
Demonstrates strong critical thinking and analytical skills
Ability to work collaboratively in a team environment
Demonstrates the ability to handle multiple assignments and carry out work independently with minimal supervision
Demonstrates responsibility for professional development
Ability to work a flexible schedule to ensure compliance with deadlines
Proficient with Microsoft applications and working knowledge of EPIC and other hospital based clinical computer systems.
Required Licenses: Registered Nurse License-NYS
Masters degree in Nursing or other health related field
Experience preparing appeals for clinical denials
Certification in Clinical Documentation Improvement
Qualified candidates must be able to effectively communicate with all levels of the organization.
NYU Winthrop provides its staff with far more than just a place to work. Rather, we are an institution you can be proud of, an institution where you’ll feel good about devoting your time and your talents.
NYU Winthrop is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sex, sexual orientation, transgender status, gender dysphoria, national origin, age, religion, disability, military and veteran status, marital or parental status, citizenship status, genetic information or any other factor which cannot lawfully be used as a basis for an employment decision. We require applications to be completed online.
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