Job Description1. Lead AHS clinical denial prevention and management initiatives to support appropriate level of care. Works closely with AHS revenue cycle leaders to complete current state assessment, evaluate, and implement leading practices for system standards and/or local market programs needed. Evaluates clinical denials and appeals data, documentation, and workflows to identify and address process and performance gaps.
2. Lead successful denials prevention and performance improvement for AHS hospitals. Monitors and manages AHS hospital performance to targets and leads corrective action plans needed to achieve organizational targets.
3. Collaborates with Executive Director of Case Management to address barriers and gaps in utilization review and authorization confirmation services. Provides hospitals with performance data analytics to make decisions and drive improvement. Works with hospital and market leaders to identify when improvement plan is needed and follows up to ensure successful execution.
4. Work with Managed Care Contracting to identify and address payer and Independent Review Organization (IRO) issues. Collects and collates data from hospitals on payer issues and IRO results. Provides AHS managed care leadership team with data to address issues with payers including avoidable days, contract violations, and process issues. Provides input to contract language to support AHS case management service needs. Participates with AHS Appeals with Physician Advisor in identifying and addressing trends with payor medical directors.
5. Provide oversight for appeals assigned to the Physician Advisor (PA) and potential account downgrades. Supports the development and implementation of clinical appeals workflow to incorporate AHS Appeals PA review prior to any account downgrade. Works with Conifer and Tenet Appeals PA to identify opportunities for improvement including documentation and process. Utilizes findings for process improvement and hospital PA and case management education. Identifies trends to address with managed care contracting and plan medical directors.
6. Uses tools to address performance barriers. Develops and implements best practices to achieve organizational goals through effectively leading and managing change in a matrix environment. Oversees the implementation of action plans and monitors progress toward goals assisting with addressing barriers and challenges and adjusting as needed in a supportive, synergistic manner. Collaborates with medical and nursing leadership, as well as case management members to develop and implement methods to optimize use of hospital and post-acute services.
7. Manages multi-disciplinary process improvement by utilizing excellent communication and servant leadership skills to challenge status quo and positively influence administrative teams and physicians to change processes to improve performance.
8. Provides analysis and education regarding regulatory and clinical changes impacting inpatient and post-acute care processes and reimbursement. Provides education and tools for educating physicians and staff regarding programs and processes.
Works in alignment with hospital and revenue cycle leadership teams and consistently demonstrates ability to:
• Conduct financial analysis, develop business plans and secure approval for programs.
• Develop strategies to manage and prevent disputes and improve revenue cycle processes.
• Build trusting relationships with hospital and revenue leaders to successfully implement new programs.
• Build collaborative partnerships and lead cross functional teams to execute on plans and proposals.
• Identify process inefficiencies via root cause analysis and design workflow to address opportunities identified.
• Develop and implement action plans managing follow up to achieve outcomes.
• Implement targeted process changes including ongoing metric monitoring and management to achieve goals and drive improvement
Supervisory Responsibilities
The UR Nurses and Insurance specialist will report to this Central UR Manager
QualificationsEducation
• Graduate of an accredited school of nursing.
• Advanced degree in Business, Nursing and/or Health Care Administration required.
Experience
• Leadership experience care and management of acute hospitalized patients.
• Experience in acute care case management,
• Case management training from a professional Case Management organization, preferred.
Required Licenses, Certifications and/or Registrations
Certificates ACMA or CCM preferred
Licenses Current state license as a Registered Nurse
Atlantic Health offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted:
Team Member Benefits
- Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members)
- Life & AD&D Insurance.
- Short-Term and Long-Term Disability (with options to supplement)
- 403(b) Retirement Plan: Employer match, additional non-elective contribution
- PTO & Paid Sick Leave
- Tuition Assistance, Advancement & Academic Advising
- Parental, Adoption, Surrogacy Leave
- Backup and On-Site Childcare
- Well-Being Rewards
- Employee Assistance Program (EAP)
- Fertility Benefits, Healthy Pregnancy Program
- Flexible Spending & Commuter Accounts
- Pet, Home & Auto, Identity Theft and Legal Insurance
Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer.
