MGR - APPEALS

UHS•Las Vegas, NV

95d

About The Position

The primary responsibility of the Appeals-Denials Manager is to receive, investigate, and manage all appeals, provider disputes, and member complaints relating to technical and clinical issues identified during the billing and payment of claims. Manages staff and the appeals workflow to assure effective and efficient resolution to claims. The position will provide resolution of the grievance situations in compliance with legal and regulatory requirements. Is a key liaison to the facilities in providing information on denials and process improvements to reduce the number and amount of denials.

Requirements

Associates or Bachelors degree in Nursing or CPC, CPC-H or CCS certification required.
Extensive knowledge of medical records is required.
Experience working in case management and with technical denials is required.
The ability to communicate clearly and concisely both verbally and in writing.
Possess a complete knowledge of state and federal regulations and requirements for effective and efficient collections.
Able to conduct clinical or compliance audits for the purpose of validating regulatory compliance.
Customer focused, providing service consistently exceeding expectations to both internal and external customers.
Computer proficiency to include work processing, spreadsheet, database, and patient accounting system.
Excellent Customer Service skills required as well as good written/oral communication skills.

Responsibilities

Receive, investigate, and manage all appeals, provider disputes, and member complaints relating to technical and clinical issues identified during the billing and payment of claims.
Manage staff and the appeals workflow to assure effective and efficient resolution to claims.
Provide resolution of the grievance situations in compliance with legal and regulatory requirements.
Is a key liaison to the facilities in providing information on denials and process improvements to reduce the number and amount of denials.