The Denials Manager will support the mission of the DCH Health System by managing the denials of the DCH Health System looking for opportunities to improve denials through billing, coding and clinical documentation opportunities. The Denials Manager will be required to have strong analytical skills and proficiently use data systems to produce standard and custom reports to support financial opportunities throughout the DCH Health System.

Experience in navigating both the clinical and billing areas of EHR systems, medical coding and billing, KPI/Dashboard/Scorecard development and reporting, operational analysis assessment, strategy development for maximizing revenue and cash collection realization, and tactical execution of related sensible policies and procedures.

1. Leads and supervises DCH denial staff for the health system.
2. Ability to manage denial projects and align teams to the corporate strategic vision.
3. Collaborates with clinical staff on the clinical appeal process for all inpatient denials assuring that proper documentation is provided to support appeals of unauthorized inpatient days or days denied for lack of documentation.
4. Oversight of the clinical appeal process for outpatient denials, i.e., outpatient prior authorization denials, radiology denials, HMO denials for specialty care where a referral was not obtained and clinical documentation is required.
5. Stays abreast of updates and changes to regulatory billing updates, regulatory requirements and organizational compliance policies to avoid audits and appeals/denials.
6. Coordinates training, operations, and other activities for Denials Team.
7. Supports Clinical Denial staff on a daily basis, keeping abreast of difficult/complex cases, and coaching, guiding as necessary.
8. Works with highest level of appeal cases; refers appropriate staff and/or physicians and works closely on development of second level appeals.
9. Collaborates in the ongoing re-design and re-engineering of Denial functions, to meet the changing needs and priorities of the organization.
10. Develops reporting mechanisms to monitor and report outcomes for implementation and improvement strategies.
11. Educates and serves as subject matter expert for the use of software programs that support Denial processes. Guides and assists IT partners with maintenance, development and upgrades of software; serving as content expert and communicating department needs.
12. Ensures compliance with state, federal, and contract payer rules.
13. Provides billing education to staff on appropriate measures to manage denials.
14. Reports any trending and process improvement initiatives to Director and key stakeholders.
15. Develop, establish and evaluate departmental and staff goals. Ensure all goals and workflows use the lean management methodology.

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

Bachelor’s degree required/Master’s degree preferred.

Two years of supervisory experience or project management experience required.

Exposure to CPT/ICD-10 coding and medical terminology.

Knowledge of billing and utilization management.

Strong computer skills required including but not limited to Microsoft Excel, PowerPoint, and the management of information systems.  

Knowledge of Medicare, Medicaid and Blue Cross regulatory requirements.

Strong organizational skills.

Must be able to read, write legibly, speak, and comprehend English.

WORKING CONDITIONS

WORK CONTEXT

• Coordinate and lead others
• Deal with external customers/vendors
• Provide business appropriate letters, memos, and emails
• Public speaking
• Work well within a group or team

• Freedom of decision making without supervision
• Understanding impact of decisions on the Health System
• Fast-paced and under time pressure

PHYSICAL FACTORS

• The Americans with Disabilities Act (ADA) requires the job description to document physical factors, including ability, activities, and requirements.

• Ability: Gross Body Equilibrium and Coordination.
• Activities: Talking, hearing, walking, repetitive motion, standing, and/or using hands to handle, control, or feel objects, tools or controls.
• Requirements: Please indicate the physical requirements of the job as one of the following:
  • Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.
•  Must be able to perform the duties with or without reasonable accommodation.
• Hearing and vision must be normal or corrected to within normal range.
• Physical presence onsite is essential.

OTHER JOB FACTORS

• Deductive reasoning, fluency of ideas, problem sensitivity, oral comprehension, oral expression, written expression, speed of closure.
• Achieve goals set forth in job, ability to adapt to surroundings and continuous change, attention to detail, initiative, independence, stress tolerance, leadership, integrity and cooperation.
• Ability to build relationships, create a support structure for those in the Health System, provide recognition to those achieving the accolades, and satisfy work task independently.