Associate Director Clinical Appeals - Denial Management

Prime Healthcare•Ontario, CA

1d•Onsite

About The Position

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 54 hospitals and has more than 360 outpatient locations in 15 states providing more than 3.0 million patient visits annually. It is one of the nation’s leading health systems with over 60,000 employees and physicians. Twenty-one of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team! The Associate Director of Clinical Appeals/Denial Management is responsible for the clinical appeals process under the Utilization review department. This position will provide leadership and oversight to the clinical appeals process for the assigned Region. The Associate Director will act as a strong advocate for proper reimbursement to hospitals in a changing health care environment and provide reports and education to the facilities for process improvement to prevent future clinical denials. The Associate Director is responsible for implementing consistent policies and practices across all facilities within the assigned region and developing monitoring tools to ensure processes are adhered to and meet regulatory compliance standards. The Associate Director will serve as liaison in Clinical Appeals for hospital and physician leaders. Perform other duties as assigned.

Requirements

Medical/ Dental Graduate or RN with current valid license and relevant education.
Master of Public Health (MPH) or related master’s degree.
Minimum of 6 years of experience with Utilization review, Clinical appeals and denials process.
4 years of supervisory experience in Utilization Management.
CRCR /CHFP certification
Knowledge of care delivery documentation systems and related medical record documents.
Strong broad-based clinical knowledge and understanding of pathology / physiology of disease processes.
Excellent written and verbal communication skills.
Excellent critical thinking skills.
Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff.
Working knowledge of inpatient admission criteria.
Ability to work independently in a time-oriented environment.
Computer literacy and familiarity with the operation of basic office equipment.
Assertive personality traits to facilitate ongoing physician communication.

Responsibilities

Provide leadership and oversight to the clinical appeals process for the assigned Region.
Act as a strong advocate for proper reimbursement to hospitals in a changing health care environment.
Provide reports and education to the facilities for process improvement to prevent future clinical denials.
Implement consistent policies and practices across all facilities within the assigned region.
Develop monitoring tools to ensure processes are adhered to and meet regulatory compliance standards.
Serve as liaison in Clinical Appeals for hospital and physician leaders.
Perform other duties as assigned.