The Clinical Denials Manager at Riverside Healthcare is responsible for overseeing and managing the staff assigned to follow-up and collection of accounts, ensuring efficient resolution of claims and denials. This role includes developing and implementing information applications related to managed care contracts, providing end-user support, and maintaining the policy and procedure database for the department. The Clinical Denials Manager works closely with patients, customers, third-party payers, attorneys, and collection agencies to resolve billing and collection questions. The role also involves identifying trends in denials, implementing solutions, and improving all system functions related to denials.

Essential Duties:

Team Leadership and Management:

• Oversee and manage the staff responsible for the follow-up and resolution of claims and denials.
• Perform timekeeping duties for the department, ensuring accurate tracking of hours worked.
• Assist staff with high-level appeal documentation and provide guidance on complex denial cases.
• Develop, implement, and maintain the policy and procedure database for the department, ensuring up-to-date and effective guidelines for staff to follow.

Clinical Denial Management and Resolution:

• Work with patients, customers, and third-party payers to resolve billing and denial questions.
• Attend payer calls monthly, escalating issues related to denials as necessary.
• Identify trends in denials, evaluate potential resolutions, and implement corrective actions to minimize future denials.
• Send monthly audit information related to commercial and advantage audits as well as RAC (Recovery Audit Contractor) to the Director of Revenue Integrity.

Regulatory and Compliance Management:

• Maintain extensive knowledge of Medicare/Medicaid/DASA/HMO/PPO and miscellaneous billing requirements as defined by contract, state, or federal law.
• Prepare documents required by payers, internal and external auditors, ensuring compliance with regulatory standards.

Collaboration and Communication:

• Work with outside attorneys and collections agencies to manage and resolve outstanding accounts.
• Implement solutions to improve the efficiency and effectiveness of the denials management process.

Nonessential Tasks

• Perform other patient accounts functions as needed to support the overall financial operations of the organization.
• Participate in special projects and initiatives as assigned by senior management.

Preferred Experience

• ICD9/CPT/Medical terminology preferred

Required Experience

• Three years of hospital revenue cycle experience within the last five years is preferred.
• Collection experience or insurance background is beneficial.
• Ability to work independently with minimal supervision.
• Excellent guest relations skills, including strong verbal and written communication abilities.
• Extensive knowledge of billing requirements across various payor types, including Medicare, Medicaid, DASA, HMO, PPO, and others.

Required Licensure/Education

• High school graduate or equivalent

Employee Health Requirements

Exposure/Sensory Requirements

Exposure to:

• Chemicals: Refer to MSDS manual
• Video Display Terminals: Average
• Blood and Body Fluids: Diagnostic composite of patients, frequent contact with intravenous devices, and high potential for contact with contaminated body fluids (blood, vomitus, stool) and administration of blood does create a high risk. Use of needleless IV system, universal precautions and protective equipment minimize risk..
• TB or Airborne Pathogens: Patient diagnostic presentations do pose high risk. Usage of protective wear and universal precautions minimize risk.

Sensory requirements (speech, vision, smell, hearing, touch):

• Speech: Required to communicate with patient/families/staff/doctors, coworkers, ancillary personnel and other department heads. Ability to ask for help.
• Vision: Required to perform necessary assessments of patient status, medication administration, CIS usage, and reading active orders and lab reports.
• Smell: Helpful to note presence of incontinence, vomitus, blood; electrical/fire safety.
• Hearing: Necessary to hear alarms, calls for help and to hear patient verbalizations. Necessary to hear lung, bowel and heart sounds. Needed to hear alarms (i.e., fire, codes via PA system).
• Touch: Necessary to perform percussive assessments and to comfort patients. Also needed to manipulate tools and equipment.

Activity/Lifting Requirements

Percentage of time during the normal workday the employee is required to:

• Sit: 10%
• Twist: 4%
• Stand: 40%
• Crawl: 0%
• Walk: 25%
• Kneel: 1%
• Lift: 10%
• Drive: 0%
• Squat: 1%
• Climb: 1%
• Bend: 30%
• Reach above shoulders: 3%

The weight required to be lifted each normal workday according to the continuum described below:

• Up to 10 lbs: Frequently
• Up to 20 lbs: Frequently
• Up to 35 lbs: Frequently
• Up to 60 lbs: Occasionally
• Up to 75 lbs: Not Required
• Up to 100 lbs: Not Required
• Over 100 lbs: Not Required

Describe and explain the lifting and carrying requirements. (Example: the distance material is carried; how high material is lifted, etc.):

Lifting patients off their beds that are unable to move independently is done with assistive lifting equipment. Horizontal movement of patients to and from carts/beds who are unable to move independently is done with assistive lifting equipment. Lifting equipment - carry 25'-150' waist high (IV bags, patient trays, charts). Filled laundry bags are filled half full so as not to weigh over 35#. Carry fire extinguishers up/down 3-4 flights of stairs and several yards in emergency.

Maximum consecutive time (minutes) during the normal workday for each activity:

• Sit: 30
• Twist: 15
• Stand: 60
• Crawl: 0
• Walk: 10
• Kneel: 0
• Lift: 5
• Drive: 0
• Squat: 2
• Climb: 1
• Bend: 15
• Reach above shoulders: 2

Repetitive use of hands (Frequency indicated):

• Simple grasp up to 10lbs
• Normal weight: Up to 5lbs
• Pushing & pulling: Up to 50 lbs occasionally
• Fine Manipulation: Typing in computer, omnicell, using pens to chart, drawing up meds in syringe and administration, starting IV's.

Leg Strength - up to 50lbs: Occasionally-(repetitive use of foot or feet in operating machine control: utilized in positioning beds during transport; x-ray, surgery or in an emergency situation from floor to floor, locking beds or cardiac chairs.)

Environmental Factors & Special Hazards

• Environmental Factors (Time Spent):
• Inside hours: 12
• Outside hours : 0
• Temperature: Normal Range
• Lighting: Average
• Noise levels: Average
• Humidity: Normal Range
• Atmosphere: Odors
• Special Hazards: Radiation, Chemical, Explosive - Chemical-drugs; Explosive-oxygen; Radiation-cesium implants and radioactive iodine therapy.
• Protective Clothing Required: Gowns, gloves, goggles, masks, HEPA masks for TB.

Pay RangeUSD $34.52 - USD $45.34 /Hr