Mgr, Clinical Denials Management

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

• 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

• 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]

• Bachelors of Nursing [Required]

• Masters degree [Preferred]

• 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.)

• 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]

• 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]

Certain positions are subject to Florida Level 2 background screening, including fingerprinting, as required by state law.

Applicants may review general information about Florida’s background screening requirements at the Florida Care Provider Background Screening Clearinghouse:
https://info.flclearinghouse.com/

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.