System Director Denials Mgmt-Payer Performance

Job Summary and Responsibilities

This is a remote position

 

The System Director of Denials Management-Payer Performance and Revenue Reconciliation is a key member of the healthcare organization's leadership team charged with meeting the organization's goals and objectives for assuring the effective, efficient utilization of health care services. This role  should be an expert on matters regarding physician practice patterns, over and under-utilization of resources, medical necessity, levels of care, care progression, compliance with governmental and private payer regulations, and appropriate physician coding and documentation requirements. Under direction of the System Vice President of Utilization Management, this role will have responsibility and accountability for creating, implementing, and managing an integrated system-wide pre-and post-claim program for monitoring and assessing payer performance regarding clinical denials, appeals, and payments. This role  will implement process innovations and work closely with insurance payers, revenue cycle, and national and region team leaders in revenue-producing areas to reduce inappropriate denials, ensure appropriate payment for services provided, and secure financial well being for the organization. This role will require communicating directly with national and region team leaders and externally with third party payers. This role  is accountable for standardizing policies, practices, workflow, and data reporting as it relates to system wide denials.

 

Essential Functions

• Provides overall strategic direction and leadership for the payer performance and revenue reconciliation team(s).
• Identifies and addresses root causes of clinical claim denials, underpaid accounts, and unpaid accounts.
• Develops and implements effective strategies to prevent future denial occurrences and/or claim underpayments.
• Minimizes unnecessary write offs and avoidable losses through targeted solutions enhancing organization cash flow.
• Develops reports and dashboards accurately reflecting denial trends and financial impact.
• Implements enhanced workflows and procedures to streamline denials management and resolution of denied claims.
• Collaborates with Utilization Management, Revenue Cycle, and Payer Strategy to implement comprehensive denials prevention and management strategies across departments; and payers.
• Monitors healthcare policies, reimbursement models, and industry best practices related to utilization management and denials management for internalization, where appropriate.
• Implements long-range strategic plans, goals and objectives for clinical denials management and claim reimbursement. Manages assigned budget and assists with the annual budget development process. Prepares cost estimates and budget recommendations. Monitors and controls expenditures.

Job Requirements

Education and Experience

 

• Doctor Of Medicine or Doctor Of Osteopathy from an accredited medical school.
• 7 years of experience working with health care delivery systems including significant experience in physician advisory.
• Minimum 5 years of leadership experience in a director level, or equivalent leadership role.
• Minimum 2 years of experience working within or in collaboration with Revenue Cycle for a health system.
• Minimum 2 years of experience performing government, managed care, and commercial appeals.
• Previous Physician Advisor/Care Management or equivalent experience.

Where You’ll Work

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees, 45,000 nurses and 25,000 physicians and advanced practice providers across 24 states and contributes more than $4.2 billion annually in charity care, community benefits and unreimbursed government programs. Together with our patients, physicians, partners, and communities, we are creating a more just, equitable, and innovative healthcare delivery system.