CHS Utilization and Appeals Manager

Catholic Health•Melville, NY

10d•Onsite

About The Position

The Utilization and Appeals Manager (UAM) proactively conducts clinical reviews and appeals according to industry accepted clinical criteria guidelines. The UAM serves as interdepartmental liaison identifying denial reasons and opportunities for improvement from both internal and external sources including regulatory agencies.

Requirements

Graduate of an accredited Nursing School or College; current New York State, R.N. License required, BSN Bachelor of Science in Nursing or Health preferred.
Minimum 5+ years of relevant clinical medical-surgical or specialty experience required as applicable to position needs.
Experienced appeals writer and Care Management experience required in an acute hospital or related managed care setting.
Required to pursue ongoing education, certification and self development to remain current with industry standards and business objectives related to Utilization and Care Management as appropriate.
Sound knowledge and skill in the use of personal computer and software for word processing and spreadsheet required. Experience with EPIC, Midas, Star and other hospital software as required.
Ability to effectively communicate with all levels of hospital staff in a verbal and written manner; demonstrated ability to be organized and efficient in prioritizing and managing assignments with minimal oversight and direction.
Demonstrates a courteous and professional demeanor, team spirit and the ability to work in a collaborative, effective manner.
Seeks clinical expertise/reference for specialty services as needed to adequately prepare clinical review and/or appeal.
Demonstrates aptitude and skill in applying sound financial and reimbursement principles to all utilization and appeal functions and reporting.
Ability to utilize critical thinking and apply sound clinical judgment and assessment skills for decision-making.
Expert knowledge of evidence based guidelines as applicable.
Knowledge of Federal, State and PRO regulations preferred.
Maintains knowledge of requirements by third party payers, regulatory agencies, and managed care entities concerning levels of care, continuity of benefits and medical necessity guidelines.
Knowledge of managed care and the current standards and trends of patient care, best practices, management tools.

Nice To Haves

BSN Bachelor of Science in Nursing or Health preferred.
Knowledge of Federal, State and PRO regulations preferred.

Responsibilities

Receives, manages and provides clinical reviews and/or submissions as required by contractual or regulatory requirements.
Researches initial denial, identifying reason for the denial and contributing factors that led to the denial and mitigates, manages and/or escalates denial when appropriate.
Submits all (initial and/or appeals) reviews and/or letters within contractual or regulatory timeframes.
Collaborates in clinical discussions with the Catholic Health Physician Advisor when appropriate.
Reviews results from managed care payors and/or regulatory agencies determinations for further action.
Manages/follow-up on certification status/appeal status with the Manage Care Payors or regulatory agencies, as needed or requested.
Handles queries from payors for additional clinical documentation.
Acts as liaison between the Utilization and Appeals Management Department and the physician of record, as required.
Communicates changes to patient status and level of care to MCC in response to physician order, or review of updated clinical information
Acts as a resource for MCC/CM regarding regulatory or managed care requirements or regulations
Meets department standards
Attends meetings as required and participates on committees as directed.
Identifies managed care/regulatory issues/compliance contributing to denial activity and report findings to Department Leadership.
Completes data tracking tools.
Participates in monthly meetings, as appropriate or required.
Meets productivity standards
Provides information, guidance and support to administrative support team.
Serves as a resource/liaison for both “intra” and “inter” departmental communications.
Receives updates regarding third party contractual changes from the Managed Care Department and applies to UM and appeals management processes.
Works collaboratively with physicians, physician office staff and other health team members to understand and help comply with payer/contract issues and appeal preparation.
Maintains strict standards for patient confidentiality and patient related information in addition to security of electronic (computer) information; complies with department, hospital, Peer Review Organization (PRO) and New York State regulations and policies on confidentiality.