Appeals Manager

The Appeals Manager is responsible to assist in the analysis and preparation of response to denial notification letters that arrive in letter and electronic format.  Collaborating with the Department Denial and Appeals Coordinators, Physician Advisors, and the clinical staff, the Appeal Manager is responsible to develop a strong appeal letter that will result in the denial being overturned providing the hospital reimbursement for the care and services provided to the patient. The Denial Manager will assist the department’s leadership develop strategies for denial prevention, improved utilization management, documentation of medical necessity and identify patterns and trends to prepare education programs for the staff on identified deficiencies to best respond to all hospital denials notification and documentation efforts. The Appeals Manager will provide timely tracking and trending of all denials and appeals, prepare weekly status reports, attend necessary meetings to assist the department attain its objective of managing denials and appeals.

-Types, utilizing a keyboard, and edits a variety of material, frequently involving technical or specialized terminology; uses a mouse to navigate computer software programs and products.

-Processes and distributes mail, telephone and fax messages according to established procedures; prepares material for mailing by letter, fax, and / or electronic transmission as required and when applicable..

-Prepares and summarizes data and reports from a variety of sources in accordance with specific instructions or procedures.

-Maintains cordial telephone presence when interacting with business associates to exchange and obtain necessary Appeal Department information; documents all telephone communications in accordance with department procedures using Care Management and other resources, escalates issues related to business associate interactions and department staff when prevented from completing job tasks.

-Assists the Administrative Manager and Director with annual review and revisions of departmental policies, and procedures as required.

-When needed, attends meetings with Director and / or Administrative Manager in order to discuss department findings and plans of correction.

- Participates in special projects as determined by the Director.

-Assists in prepearing and maintaining all the necessary documents and manuals to comply with regulatory and inspecting agencies such as IPRO, The Joint Commission Regional and Medical Audit Contractors, and other licensing, accrediting, or review agencies.

-Provides regular and special reports, in writing and verbally, regarding department denial and appeals activities and the collection and processing of department appeals reporting information; including by not limited to appeals status, and outcomes by department denial coordinators, physician advisors, and the clinical staff.

-Keeps current on concepts, techniques, and methods relative to areas of responsibility.

-In conjunction with the Department’s leadership team, helps build enthusiasm, stability, teamwork, and competence among employees through supervision, individualized evaluation and counseling, training and praise for a job well done.

-Maintains knowledge of healthcare plan medical necessity requirements, DRG’s, insurance plan benefits related to authorization of care, IPRO, CMS, The Joint Commission, and other nationally recognized criteria to meet medical necessity for patient care services.

-Collaborate with Social Work, Health Information Management (Medical Records) Nursing, Admission and Patient Access, and the Medical Staff to address length of stay, avoidable day and barriers to discharge processes pertaining to utilization management.

-Liaisons and coordinates with other hospital departments as needed to:

• Optimize interdepartmental relations and communications related to educational needs for meeting medical necessity, training and education of InterQual criteria and guidelines.
• Address problems related documentation improvement activities to assure capture of medical necessity components of care
• Promote best possible patient care practices related to Appeal Department activities

-Keeps current on concepts, techniques, and methods relative to areas of responsibility.

-Maintains a working knowledge of InterQual Criteria in order to apply the criteria and utilize in the formulation of a strong appeal letter.

-Reviews all denial notifications in letter and electronic format to determine dates required for timely response by the department physician advisors and clinical staff.

-NYS  Registered Nurse required

-The Appeal Manager must have excellent verbal and communication skills as a large part of the job requires telephone communication and interaction with healthcare agencies staff and medical directors, physicians, nurses, external agency executives and administrative leadership as well as hospital department leaders.. The Appeal Manager should have excellent computer keyboard and mouse skills, be willing to learn electronic medical record systems and data entry into an electronic database system.

-The Appeal Manager should be a nurse who has 3-5 years or more of experience in healthcare administrative management and services work. On the job or formal training in certified case management, denial and appeals management from a business school in office management, professional trade association, a closely related area is preferred.

-The Appeal Manager should have experience as a nurse in acute care clinical setting who is able to providing guidance, direction and training to nurses, physicians, clerical and other clinical staff members