Yale New Haven Health System

CLINICAL REIMBURSEMENT MANAGER

US-CT-Bridgeport
Job ID
63281
Department
ACCOUNTING
Category
MANAGEMENT/LEADERSHIP
Position Type
Full Time Benefits Eligible
Scheduled Hours
40
Requisition ID
2017-16569

Overview

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values—integrity, patient-centered, respect, accountability, and compassion—must guide what we do, as individuals and professionals, every day.

At Bridgeport Hospital, we are committed to providing quality medical care and treatment that is coordinated and centered on the patient’s specific needs. We strive to achieve benchmarks as a Patient Centered Medical Home and provide health care in a setting where patients are at the center of their care team. All employees of Bridgeport Hospital are part of the patients care team and contribute to the team approach of promoting access, continuous, comprehensive care and work to provide quality improvement in the care provided to their patients.

This position reports directly to the Sr. Vice President, Finance.  Responsible for all aspects of Denial Management.  Works closely with System Billing Office in ensuring a comprehensive denial review and appeal process.  Serves as a strong liaison to the Utilization Review staff and Physician Advisors in ensuring an appropriate utilization review and patient status assignment process.  Serves as a clinical liaison to Access/Verification, Contracting, and Compliance.


EEO/AA/Disability/Veteran

Responsibilities

    1. Denial Management
      • Prevent and decrease the number of concurrent denials by working collaboratively with Access/Verification, SBO, Care Coordination and Utilization Review staff, physicians and payors.
      • Implement and monitor formal appeal process for retrospectively denied inpatient claims.
      • Track, analyze and report denial information in conjunction with other related systems/departments.

     

    1. Utilization Review Liaison
      • Monitor and track on-going utilization review activities to identify key trends and issues.
      • Serve as resource for Utilization Review staff in payor policies and governmental regulations.
      • Identify and educate Case Management staff on new trends related to reimbursement, managed care contracting and utilization review.

     

    1. Recovery Audit Contractor Program Liaison
      • Serves as Clinical Liaison to HIM for external Medicare audit program.
      • Coordinates RAC review, denials and appeal process for clinical cases.
      • Tracks, analyzes and reports RAC denial information and reports information accordingly to appropriate departments.

     

    1. Other External Audit Activities
      • Oversees other external commercial or governmental audits, i.e., Medicaid Integrity Contractors.
      • Tracks, analyses and reports audit results to appropriate departments.

     

    1. Related Administrative Responsibilities
      • Serves as chair of Bridgeport Hospital Denial Committee.
      • Serves on Yale New Haven Health System Denial Committee and RAC Sub-committee.
      • Participates in appropriate CHA committees as necessary.
      • Serves as member of Patient Care Review Committee as part of Utilization Management Plan.

     

    1. Other Related Duties
      • Identify opportunities to improve revenue cycle activities as they pertain to reimbursement and clinical management.
      • Lead projects to influence operations and system changes to ensure compliant documentation and billing procedures.
      • Maintain positive and influential relationships with interested departments, companies, legislative bodies and regulatory agencies.

Qualifications

EDUCATION:  RN required

 

EXPERIENCE:  At least 5 years of acute care clinical experience and utilization review experience preferred.

 

SPECIAL SKILLS:

Knowledge of Excel, Word.  Knowledge of InterQual criteria required.  Strong positive interpersonal skills and communication skills required.  Strong public speaking presentation skills preferred.

 

ACCOUNTABILITY: 

Responsible for all aspects of denial management and audit contractors as related to the overall revenue cycle at Bridgeport Hospital.  In personal and job-related decisions and actions, consistently demonstrates the value of integrity (doing the right thing), patient centered care (putting patients and families first), respect (valuing all people and embracing all differences), accountability (being responsible and taking action) and compassion (being empathetic).

 

COMPLEXITY:  Serves as the on-site expert in Clinical Denial Management and Utilization Review.

 

LICENSURE/CERTIFICATION: RN license required.

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