Director, Home Health Grievances & Appeals

CenterWell Home Health • Louisville, KY

2d • Remote

About The Position

Become a part of our caring community and help us put health first The Director Denials Management provides leadership for the audit, appeal and review process to preserve and recover revenue while maintaining the highest level of clinical and regulatory integrity and compliance. Manages the Denials Management data analytics, denial and appeal process. The Director, Home Health Grievances & Appeals assists members, via phone or face to face, further/support quality related goals. Investigates and resolves member and practitioner issues. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes, and implements strategic plans, drives goals and objectives, and improves performance. Provides input into functions strategy.

Requirements

• Bachelor's degree in Nursing or related field
• 10-15 years progressively responsible experience in home health or hospice industry that includes performance improvement and outcomes measurement
• 5 years' experience in a supervisory or teaching role
• Thorough knowledge of health care policy, industry and related clinical practice
• Knowledge in the interpretation and application of regulations and performance improvement standards
• Strong Project management principles and clinical policy development/implementation required
• Expert knowledge of all Medicare regulations and appeals processes
• Excellent analytical skills with ability to interpret and apply regulatory requirements
• Excellent verbal/written communication and presentation skills
• Advanced knowledge with Payer requirements, ADR requests, Denials, Appeals, RAC/ZPIC and CERT responses
• Must be able to work well independently and in a team environment
• Excellent communication and organization skills
• Strong attention to detail
• Healthcare industry experience preferred
• Must read, write and speak fluent English
• Must have good and regular attendance
• Approximate percent of time required to travel: 30%

Nice To Haves

• Master's Degree preferred
• Licenses/Certification: RN, PT or OT preferred
• More than 3 years of grievance and appeals experience
• Strong knowledge in Microsoft Access or experience with SQL Server databases
• Previous experience processing medical claims
• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish

Responsibilities

• Oversee the process for direction and support to clinical and operational leadership regarding Medicare and governmental audit trends, denials, and any CMS initiative and/or demonstration projects.
• Collaborates with leadership team in the development of an education plan to improve processes to preserve and recover revenue.
• Analyzes region-wide outcome indicators to measure achievement of quantitative and qualitative standards.
• Assists in the development, implementation and analysis of internal and external benchmarking programs to measure the region's effectiveness in improving performance
• Maintains region-wide Performance Improvement program which includes Customer Satisfaction, complaints, infection monitoring, Incident Reporting, and quarterly branch PI activity
• Provides feedback and recommendations for changes to policies and processes, procedures and systems to enhance measures taken to improve performance
• Communicate with Corporate leadership, Regional and Divisional leaders as appropriate to resolve issues that may place patients or the company at risk
• Oversee educational in-services based on analysis of PI data and activities
• Acts as a resource for the Operations Support team and communicates Performance Improvement results
• Participate in special projects and performs other duties as assigned.

Benefits

• Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being.
• Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work.
• Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Number of Employees: 5,001-10,000 employees