Director, Denial Resource Center

Director, Denial Resource Center

The Director, Denial Resource Center is responsible for the strategic planning, evaluation, and operational oversight of the clinical denial management function for Baylor Scott and White Health (BSWH). The Director, Denial Resource Center will lead a highly skilled team of Registered Nurses, Certified Coding Specialists, Complex Appeal Specialists, Payer Liaisons and Collectors focused on appealing hospital and professional clinical and coding denials, as well as Recovery Audit Contractors (RAC) denials. This role will be responsible for developing and implementing policies, procedures and performance metrics to improve appeal success rates, ensure regulatory compliance and optimize reimbursement outcomes. Will lead external resources through vendor or contractor management in support of clinical denial management operations. Identifies, analyzes and reports on significant denial trends and patterns to key stakeholders. This will include close partnership with the BSWH utilization management function to gather information and resolve issues with efficiency resulting in improved utilization of appropriate patient care services. Collaborates with medical, clinical, HIM and other BSWH departments to ensure BSWH patient care services are necessary, timely and cost-effective.

Essential Functions of the Role

Leads and manages a multidisciplinary team including RNs, certified coders, appeal specialists, and administrative staff supporting the clinical denial management function for BSWH.

Recommends and implements strategic and operational plans and priorities for clinical denial management aligned to BSWH overall business objectives.

Directs daily operations of clinical denial management, including the development and implementation of utilization policies, procedures, and work processes.

Develops key operational and financial reports and establishes key metrics essential for monitoring daily operations.

Monitors department performance indicators and identifies opportunities for improving processes.

Identifies denial trends and leads initiatives to reduce preventable clinical denials.

Develops and presents performance dashboards and reports for senior leadership, hospital senior leadership, and senior medical staff including denials from all payers, Medicare / Medicaid audit activities and key contract enforcement activities.

Collaborates with Centralized Business Services (CBS) and other revenue cycle departments to streamline referral and appeals workflows.

Supports education and training initiatives to improve documentation and clinical justification practices.

Serves as a liaison to outside vendors and contracted services supporting the clinical resource management functions.

Key Success Factors

Bachelor's degree in healthcare administration or related field. Master's degree preferred.

5+ years of experience in healthcare revenue cycle

3+ years of experience in a leadership role

3+ years Epic experience preferred

Proven ability to lead cross-functional teams in a complex healthcare environment

Strong understanding of payer denial codes, appeal strategies and regulatory frameworks.

Familiarity with RAC audit processes preferred

Experience collaborating across multiple departments and clinical disciplines within a large, complex healthcare organization preferred.

Excellent presentation skills and ability to create executive-level presentations and deliverables

Ability to manage multiple priorities and drive performance improvement initiatives.

Strong problem-solving and critical thinking skills.

Qualifications

EDUCATION - Bachelor's or 4 years of work experience above the minimum qualification

EXPERIENCE - 3 Years of Experience

As a health care system committed to improving the health of those we serve, we are asking our employees to model the same behaviours that we promote to our patients. As of January 1, 2012, Baylor Scott & White Health no longer hires individuals who use nicotine products. We are an equal opportunity employer committed to ensuring a diverse workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.