Cottage Health seeks a Manager, Clinical Revenue Cycle for their Clinical Denials and Appeals department responsible for the overall management of utilization review processes and clinical denials between Cottage Health and outside payers. The manager is also responsible for processes associated with patient status (inpatient/outpatient) within Cottage Health. This individual serves as a liaison and point of contact for all patient status and clinical appeal inquiries. Responsibilities include:

The manager’s primary responsibility is to oversee utilization review functions and to ensure accurate patient status throughout the health system. This includes but is not limited to accurate patient statusing, building the EMR to foster a successful UR program, working with physicians to ensure patient status, working with EMR tools to assist with patient status determination, providing continuous education to clinical providers and staff. 
  The manager actively manages, maintains and communicates clinical denials and appeals activity to appropriate stakeholders. This includes, but is not limited to, the compilation of management reports such as: 1) denials in progress, 2) wins/partial wins/losses, 3) cases where Cottage Health has elected not to appeal based on chart documentation/support, and 4) identified cases pending review. 
  Concurrent with these activities, the manager will identify and report on the categorization of denials, suspected or emerging trends related to payer denials and/or slow payment, and lead action planning for correction and process changes to eliminate avoidable denials. 
  The manager will actively collaborate with clinical and/or administrative department leaders/physicians throughout the organization to educate on current denials trends, prevention, issues related to utilization review or patient status. 
  The manager will assist the director of revenue cycle operations in providing clinical insights to problems and solutions facing the revenue cycle department. As an active member of the Utilization Review Committee, the manager will regularly report on outcomes of utilization review, denials and appeals. 
   The manager will also coordinate, monitor, implement, manage and report back on educational activities for performance improvement.

QUALIFICATIONS:
All job qualifications listed indicate the minimum level necessary to perform this job proficiently. 
 

Education:

Minimum: Bachelor's degree.

Certifications, Licenses, Registrations:

Minimum: Current nursing license in good standing. If not an active California nursing license, would need to become certified in California upon hire. Preferred: Milliman Care Guidelines Certification.

Technical Requirements:

Minimum: Must be able to demonstrate an understanding of InterQual and Milliman guidelines, community standards relevant to inpatient acute care. Must be able to exercise independent discretion and judgement, and act at all times with the highest degree of professionalism and objectivity. Must be computer literate and able to manage Outlook, Word and Excel programs, prepare charts and graphs, and analyze data to identify trends and opportunities for process improvement. Knowledge of various spreadsheet applications, including Microsoft Word. Preferred: Knowledge of revenue cycle functions and processes.

Years of Related Work Experience:

Minimum: 3 years of experience working with utilization review or case management in an acute care facility or health system. 2 years supervisory experience, which can be part of the 3 years in UR noted above. Preferred: 2 years direct patient care experience as an RN in an acute care setting.