Mgr, Clinical Denials Management

Schedule

Full time

Shift

Day (United States of America)

Address

900 HOPE WAY

City

ALTAMONTE SPRINGS

State

Florida

Postal Code

32714

Job Description

• Manages daily operations of the clinical denials management team
• Supervises, coaches, and develops clinical denial management specialists
• Monitors team performance against established metrics and productivity standards
• Reviews and approves clinical appeals for accuracy and quality
• Analyzes clinical denial trends and develops remediation strategies
• Collaborates with clinical leadership, physicians, and utilization management on denial prevention
• Coordinates with payers on complex clinical denial issues and escalations
• Ensures compliance with all regulatory requirements and policies
• Prepares and presents reports on clinical denial performance
• Participates in hiring, training, and performance management processes
• Identifies opportunities for process improvement and implements solutions
• Performs other duties as assigned

Knowledge, Skills, and Abilities

• Strong knowledge of clinical documentation, medical terminology, and disease processes [Required]
• Comprehensive understanding of CPT, HCPCS, ICD coding systems, and clinical billing requirements [Required]
• Knowledge of payer policies, regulations, and clinical denial processes for government and commercial payers [Required]
• Understanding of utilization review criteria including MCG and InterQual [Required]
• Demonstrated leadership skills with ability to supervise and develop staff [Required]
• Strong analytical skills with ability to interpret data and identify trends [Required]
• Excellent written and verbal communication skills [Required]
• Proficiency in Microsoft Suite applications and healthcare information systems [Required]
• Ability to build collaborative relationships across departments [Required]
• Proficiency with Epic EHR system [Preferred]
• Experience with process improvement methodologies [Preferred]

Education

• Bachelors of Nursing [Required]
• Masters degree [Preferred]

Field of Study

• RN with Bachelor's degree in Nursing, Management or related healthcare field such as: Healthcare Management, Risk Management or Social Work, or RN with at least 5 years direct clinical experience, 8 years Utilization Management experience, demonstrated history of concurrent/post-remit denial management and avoidance experience
• Secondary Bachelor's Degree (in Business, Healthcare or Health Services Administration, Health Information Management, Communications, Finance, Accounting, Public Administration, Human Resources, Management, or Marketing)
• (in Nursing, Health Management, Business Administration, Finance, or other related area.)

Work Experience

• 2+ in a supervisory/managerial position in a similar-sized hospital [Preferred]
• 4+ related work experience in utilization review, care management, revenue integrity, denial management, clinical documentation improvement, or the center for medicare and medicaid services [Preferred]
• Varied clinical experience including nursing in ED, ICU/CCU, OB and/or nursing administration position such as Nurse Manager or Assistant nurse manager [Preferred]

Licenses and Certifications

• Accredited Case Manager (ACM) [Required] OR
• Registered Nurse (RN) [Required]
• Certified Case Manager (CCM) [Preferred]
• Certified Billing and Coding Specialist (CBCS) [Preferred]
• Registered Health Information Administrator (RHIA) [Preferred]
• Certified Revenue Cycle Rep (CRCR) [Preferred]

Pay Range

$85,529.67 - $159,089.69