Manager of Clinical Appeals

Overview

Manager of Clinical Appeals is located in the Health System Shared Services | Revenue Cycle Clinical Support. The Revenue Cycle Clinical Support Office (RCCS) is an area within Access and Revenue Cycle Management Shared Services responsible for Clinical Pre-Certification, Case Reviews, Pre-billing edits, in-patient account validations, supporting Utilization Management, Peer to Peer processes, complex billing scenarios, audits (governmental, commercial, compliance, and internal), clinical appeals and denial management.

RCCS supports cash collection through these functions.

The role is responsible for the daily operational management of Revenue Cycle Clinical Support staff, primarily involving oversight of clinical appeals and denial analysis, resolution, and prevention for The Ohio State University Health System. The position implements and supports the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center. It functions within multidisciplinary teams and leads staff on analysis and resolution of a variety of administrative and clinically related third-party payer denials and drives denial prevention efforts.

The duties require clinical knowledge to interpret documented clinical information and apply medical necessity guidelines to determine appropriateness for services, including the appropriate level of care (Inpatient or Observation). It is a Subject Matter Expert (SME) for commercial and governmental payer requirements and audits such as RAC, MAC, QIO, etc. It maintains awareness of state and national health care trends, JCAHO, CMS, and third-party payer policies and guidelines.

It provides thorough support for escalating inappropriately denied claims to payers and external entities and partners with Managed Care to seek resolution and appropriate reimbursement.

• Serve as SME and lead team members in understanding critical components of Scheduling, Financial Counseling, Pre-Certification, Admissions/Discharges/Transfers, Clinical workflows and documentation, Revenue Management, Charge Description Master, Coding (Diagnosis, HCPCS, Revenue Codes, Procedure Codes, Modifiers, etc.), Medical Information Management, Release of Information, Case Management, Utilization Management, Clinical Documentation Improvement, Compliance, Managed Care, Legal, Finance, Transplant workflows, Billing, Follow Up, Cash Posting, and related areas.
• Guide staff on determining the strength of an appeal and author effective appeal letters. Help staff understand how payer remits, denial/remark codes, payer policies and manuals, and managed care contract terms impact denials.
• Analyze accounts prior to adjustment to ensure all appropriate steps have been taken to obtain payment.
• Conduct quality assurance reviews and drive continuous process improvement to increase recoveries while maintaining lower AR.
• Foster independence, adaptability to change, and focus on overturning denials, increasing recoveries, and reducing AR through collaboration with leadership and other departments.
• Develop and implement policies, procedures, workflows, and auditing procedures. Support the incorporation of technology to improve workflows. Serve as a resource on governmental regulatory interpretation. Engage with physicians, physician leaders, administrators, and other departments.

• Bachelor’s degree in nursing with current license required; advanced degree preferred.
• Minimum of 5 years clinical care experience, caring for patients and understanding the physician’s plan of care.
• Minimum of 8 years denials and appeals experience.
• Five years of management experience in denials and appeals.
• Experience collaborating with physicians and their designees.
• Strong analytical skills with ability to make educated decisions.
• Extensive knowledge of clinical operations and patient flow.
• Skilled at synthesizing large volumes of information and communicating concisely, verbally or in writing.
• Proficient in Microsoft Office products (Word, PowerPoint, Excel, SharePoint, Teams, One Note, etc.).
• Proficient in Adobe; proficient in using email, fax, copy machines, and internet browsers.
• Proficient at typing; able to multitask and navigate multiple applications (IHIS, MS Office, 3M, payer websites/applications) efficiently.

• Location:
  
  Ackerman Rd, 660 (0242)
• Position Type:
  Regular
• Scheduled
  
  Hours:
  
  40
• Shift: First Shift

Final candidates are subject to successful completion of a background check. A drug screen or physical may be required during the post-offer process. The Ohio State University and Wexner Medical Center are equal opportunity employers, including veterans and individuals with disabilities.

The university adheres to the Ohio Revised Code requirements regarding open and rigorous intellectual inquiry, equal opportunity, and related ethical standards.