All the benefits and perks you need for you and your family: - Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance
- Paid Time Off from Day One
- 403-B Retirement Plan
- 4 Weeks 100% Paid Parental Leave
- Career Development
- Whole Person Well-being Resources
- Mental Health Resources and Support
- Pet Benefits
Schedule: Full time
Shift: Day (United States of America)
Address: 900 HOPE WAY
City: ALTAMONTE SPRINGS
State: Florida
Postal Code: 32714
Job Description: - Manages daily operations of the clinical denials management team
- Supervises, coaches, and develops clinical denial management specialists
- Monitors team performance against established metrics and productivity standards
- Reviews and approves clinical appeals for accuracy and quality
- Analyzes clinical denial trends and develops remediation strategies
- Collaborates with clinical leadership, physicians, and utilization management on denial prevention
- Coordinates with payers on complex clinical denial issues and escalations
- Ensures compliance with all regulatory requirements and policies
- Prepares and presents reports on clinical denial performance
- Participates in hiring, training, and performance management processes
- Identifies opportunities for process improvement and implements solutions
- Performs other duties as assigned
Knowledge, Skills, and Abilities: - Strong knowledge of clinical documentation, medical terminology, and disease processes [Required]
- Comprehensive understanding of CPT, HCPCS, ICD coding systems, and clinical billing requirements [Required]
- Knowledge of payer policies, regulations, and clinical denial processes for government and commercial payers [Required]
- Understanding of utilization review criteria including MCG and InterQual [Required]
- Demonstrated leadership skills with ability to supervise and develop staff [Required]
- Strong analytical skills with ability to interpret data and identify trends [Required]
- Excellent written and verbal communication skills [Required]
- Proficiency in Microsoft Suite applications and healthcare information systems [Required]
- Ability to build collaborative relationships across departments [Required]
- Proficiency with Epic EHR system [Preferred]
- Experience with process improvement methodologies [Preferred]
Education: - Bachelors of Nursing [Required]
- Masters degree [Preferred]
Field of Study: - RN with Bachelor's degree in Nursing, Management or related healthcare field such as: Healthcare Management, Risk Management or Social Work, or RN with at least 5 years direct clinical experience, 8 years Utilization Management experience, demonstrated history of concurrent/post-remit denial management and avoidance experience
- Secondary Bachelor's Degree (in Business, Healthcare or Health Services Administration, Health Information Management, Communications, Finance, Accounting, Public Administration, Human Resources, Management, or Marketing)
- (in Nursing, Health Management, Business Administration, Finance, or other related area.)
Work Experience: - 2+ in a supervisory/managerial position in a similar-sized hospital [Preferred]
- 4+ related work experience in utilization review, care management, revenue integrity, denial management, clinical documentation improvement, or the center for medicare and medicaid services [Preferred]
- Varied clinical experience including nursing in ED, ICU/CCU, OB and/or nursing administration position such as Nurse Manager or Assistant nurse manager [Preferred]
Licenses and Certifications: - Accredited Case Manager (ACM) [Required] OR
- Registered Nurse (RN) [Required]
- Certified Case Manager (CCM) [Preferred]
- Certified Billing and Coding Specialist (CBCS) [Preferred]
- Registered Health Information Administrator (RHIA) [Preferred]
- Certified Revenue Cycle Rep (CRCR) [Preferred]
Physical Requirements: (Please click the link below to view work requirements)
Physical Requirements - https://tinyurl.com/23km2677
Pay Range:$85,529.67 - $159,089.69
Background Screening Requirement (Florida Law) Certain positions are subject to
Florida Level 2 background screening, including fingerprinting, as required by state law.
