The Clinical Denials and Appeals Manager will be responsible for the administration and management of the SSC clinical appeals and all other appeals as designated. This responsibility will include but not limited to collaboration with physician advisors, case managers, revenue cycle personnel and payers to appeal denials. This position will report directly to the Operations Director of Denials and Appeals. The Clinical Denials and Appeals Manager must be a resource to HIM, Business Office, Case Management and department directors for all processes in the revenue cycle.

Essential Duties and Responsibilities

• Provide on-going education and support to SSC Appeal staff, Case Management staff, and revenue cycle staff as needed.
• Provide oversight and coordination of the appeals process by communicating directly with auditors, payers and facility case managers, including requests for documentation and filing of responses and levels of appeals.
• Works with all members of the appeals team to aggressively appeal all denials.
• Develop and maintain a structured standardized process for facilitating clinical appeals at all levels. Maintains oversight of deadlines and timelines for appeals at all levels. Develops and maintains policies and procedures for all appeals processes
• Prepares and reports on payer denial activity to Operations Director, CFO, Hospital Leadership, corporate division and SSC-Nashville leadership staff as requested.
• Assist facilities with denial and/or appeals processes as needed up to and including process, documentation, and software training.
• Ensures the appeals team enters all appropriate data points into the software system for timely reporting of all activity.
• Develop processes to maintain continued updates to appeals processes. Maintain all policies and procedures for the SSC Appeals Department as well as facility specific guidelines and process flow.

Qualifications

Required Education:
Associates or Bachelor’s Degree in Nursing

Required Experience:
Minimum of 5 years of clinical nursing experience with supervisory experience included.
Preferred Experience:
Minimum of 5 years of clinical nursing experience with supervisory experience preferably in a revenue cycle setting. Utilization review and/or case management experience preferred. Knowledge of medical records documentation, CPT coding, HCPCS coding, DRG’s, and billing compliance program rules.

Required License/Registration/Certification:
LPN or RN with current license to practice in state.
Computer Skills Required:
Intermediate knowledge of Microsoft Office tools or Google platforms