Clinical Appeals Manager - UofL Health

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Location:250 E Liberty Street Louisville, KY 40202 

About UofL Health 
UofL Health is a fully integrated regional academic health system with nine hospitals, four medical centers, Brown Cancer Center, Eye Institute, nearly 200 physician practice locations, and more than 1,000 providers in Louisville and the surrounding counties, including southern Indiana. Additional access to UofL Health is provided through a partnership with Carroll County Memorial Hospital.  Affiliated with the University of Louisville School of Medicine, UofL Health is committed to providing patients with access to the most advanced care available. This includes clinical trials, collaboration on research and the development of new technologies to both save and improve lives. With more than 13,000 team members – physicians, surgeons, nurses, pharmacists and other highly-skilled health care professionals, UofL Health is focused on one mission: to transform the health of communities we serve through compassionate, innovative, patient-centered care. For more information on UofL Health, go to www.uoflhealth.org.

Job Summary:

Manage team of 10-12 clinical reviewers and oversee Facility clinical claim denials by developing strategies to overturn insurance payor processing and proactively determine root cause and solutions to prevent denials for the UofL Health System.  Clinical support will include pre-bill edits, payment denials, and pre/post-payment audits from insurance carriers or designated third party vendors as related issues such as medical necessity, experimental determinations, medically unlikely edits, non-covered services, and/or documentation.  This position will collaborate with Revenue Cycle Leadership, Case Management and clinical service areas, Payor Relations and Contracting Department.

• Oversee clinical appeals team to ensure timely and quality denial resolution through development of policies, procedures, and training materials necessary to drive process improvement and staff performance.
• Implement processes to track, trend, and reduce denials based on “root causes” across the organization with monthly reporting for Revenue Cycle leadership.
• Collaborate with Care Management and HIM Coding managers on feedback for denials related to utilization management/coding as appropriate with escalation as needed.
• Ensure Audit Recovery claims from Medicare/Medicaid or their vendor partners are received, tracked and appeals submitted timely.
• Research commercial and governmental medical payor policies, regulations, and clinical abstracts related to claims payment to evaluate and appeal denied claims as well as preventing future denials.

• Communicate effectively with providers and internal stakeholders to provide updates on denial trends and patterns so they can be efficiently shared to aid progression towards resolution.

• Analyze medical records or other medical documentation to validate services, tests, supplies and drugs performed for accuracy related to the billed charges.

• Perform retrospective authorization requests for services already performed as needed.

• Establish denial prevention procedures in support of billing staff for targeted pre-bill edits for identified clinical issues.

• Support global denial prevention and mitigation efforts throughout the health system by attending denial prevention meetings and/or payor representative meetings.

• Communicate with physicians and multidisciplinary health system team members to effectively utilize all available resources to ensure strong and efficient appeals are submitted.

• Maintain compliance with all company policies, procedures, and standards of conduct.

• Perform other duties as assigned.

Education:

• Bachelor’s degree in nursing (required).

Experience:

• 5 or more years of clinical experience (required).
• Experience with appeals and/or denial processing (preferred).
• Clinical nursing experience working in a hospital setting – ER, Critical Care, or Diagnostic Services (preferred).
• CCM (certified case manager), CPUM (certified professional in utilization management) or other relevant certification (preferred).

Licensure:

• Active, unrestricted registered clinical license (required).

Certification:

• CCM (certified case manager), CPUM (certified professional in utilization management) or other relevant certification (preferred).