Manager Denials Prevention & Appeals Operations

Description

Summary :

The Manager, Denials Prevention & Appeals Operations is responsible for the direct oversight of daily operations of clinical denial prevention and Utilization Review (UR) activities, including daily collaboration with physicians as well as payers to ensure all hospital inpatient stays / days are approved for medical necessity. This position will work closely with the Denials Prevention & Appeals Administration Manager to guide the development and implementation of new programs and related workflows, policies, procedures for all service lines, and serve as a resource for internal departments, team members, providers, delegates, and community partners. In addition, the Manager Denials Prevention & Appeals Operations is responsible for supervising nurses and coordinators to ensure that all administrative denial prevention processes are performed in accordance with all applicable state and federal regulatory requirements, organization policies and procedures and business requirements focusing on concurrent denials prevention and management. This role requires a strategic thinker who can collaborate effectively with various departments to ensure compliance with regulatory requirements and optimize the utilization review process.

Responsibilities :

• Lead and manage daily operations of the corporate Denial Prevention & Appeals team, ensuring timely and appropriate medical necessity reviews.
• Supervise and support Denial Prevention nurses and non-clinical staff, including training, coaching, performance evaluations, and ongoing development.
• Conduct performance evaluations and provide coaching and feedback to team members.
• Collaborate with Manager Denials Prevention & Appeals Administration to oversee UR processes for inpatient, outpatient observation and outpatient in-a-bed services, ensuring compliance with state, federal, and payer regulations.
• Ensure the integration of denials prevention operations such as prior authorization, initial and concurrent review, and denials management into other internal and external teams / departments including Denials Management and Care Coordination
• Conduct clinical assessments to evaluate the appropriateness of admissions, continued stays, and discharge planning, ensuring that care is medically necessary and meets established medical necessity criteria or 2 MN Rule, depending upon payer.
• Perform oversight and assignment of caseload across various UR functions including routine and ad hoc audits and monitoring of corrective action plans.
• Utilize clinical criteria (e.g., InterQual, MCG) and the 2 MN Rule to guide decision-making and ensure the delivery of appropriate care.
• Oversee the management of concurrent denials, ensuring timely and accurate responses to payer requests for information and documentation.
• Establish and maintain effective interpersonal relationships with all local Care Coordination / Discharge Planning team members and key stakeholders such as VPMAs, PAs and attending physicians.
• Resolve or facilitate resolution of problematic and / or complex issues by escalating to appropriate management / leadership colleagues.
• In collaboration with local CM Directors, Ensure UR Committee preparedness. Prepares and present reports on utilization review outcomes, compliance metrics, and performance indicators to hospital leadership and for the UR Committee.
• Attend off-site meetings, upon request.
• Maintains a clinical appeal process for all inpatient denials assuring that proper documentation is provided to support appeals of unauthorized inpatient days or days denied for lack of documentation, including concurrent denials.
• Works collaboratively with the Physician Advisors or attending physicians to support concurrent appeals.
• Monitor and analyze utilization data to identify trends, variances, and opportunities for improvement in resource allocation and patient care.
• Ensure that the UR department maintains compliance with all relevant accreditation and regulatory requirements.
• Responsible for monitoring and identifying payer trends / behaviors and escalation to leadership for assistance with resolution.
• Shares management coverage with AVP Care Coordination and Manager Denials Prevention & Appeals Administration.
• Demonstrates regular, reliable and predictable attendance
• Maintain and model the organization's values
• Performs other duties as required.

Education Skills Experience

Working Conditions :

Manual : Some manual skills / motor coord & finger dexterity

Occupational : Little or no potential for occupational risk

Physical Effort : Sedentary / light effort. May exert up to 10 lbs. force

Physical Environment : Generally pleasant working conditions

Company : Nuvance Health

Org Unit : 2092

Department : Care Coordination

Exempt : Yes

Salary Range : $51.31 - $95.29 Hourly