About this role
Adventist Health Ukiah Valley has been deeply connected to the community we serve since 1956. We are comprised of a 50-bed acute care medical center, level IV trauma center, level II intensive care nursery services, extensive physical rehabilitation program, outpatient surgery and diagnostic center and advanced wound care center. Ukiah is a unique small town that charms you with its rich character, arts, vineyards and natural surroundings. Ukiah beckons you to explore all that the valley has to offer amidst our 300 days of sunshine each year. We are also conveniently located just two hours north of San Francisco and 45 minutes from the Pacific Coast.
Job Summary:
Reviews patient encounters and medical records to determine if improvement opportunities exist through either technological or communication enhancements. Supports the execution of system-wide strategic initiatives, process re-design, root cause analysis, metric/report development as it relates to clinical reviews and denial management. Analyzes, monitors, reports findings, and provides recommendations on key report sets to Adventist Health leadership and utilization management committee. Works closely with key departments (e.g., on-site care management, medical staff, HIM/coding, patient financial services, etc.) to review and obtain the medical documentation required to streamline the adjudication process. Tailors communications to respective audiences (e.g., system leaders versus regional leaders) to ensure that specific mitigation action plans are created and implemented. Supports and facilitates the design as well as implementation of utilization management data collection and reporting methodologies. Develops analytic models and trending displays and dashboards to inform executive leaders, oversight committees and Key stakeholder of process and outcomes of high priority metrics, functions and opportunities for improvement and progress to goals. Understands, utilization management and its impact on claim adjudication.
Job Requirements:
Education and Work Experience:
- Associate's/Technical Degree in finance or business or equivalent combination of education/related experience: Required
- Bachelor's Degree in mathematics, statistics, economics or finance or equivalent combination of education/experience: Preferred
- Three years' acute care hospital revenue cycle experience: Preferred
Essential Functions:
- Creates a regularly scheduled report set of key metrics (e.g., denials by category and market, overturned denial rate, write-off rate, etc.) related to the case management & revenue cycle team that is distributed to Adventist Health leadership. Uses data to investigate areas, such as clinical denials, to determine root-cause and subsequent mitigation action plans.
- Collaborates with necessary personnel or departments to implement action plans, using either verbal or written communication to emphasize importance of an issue. Prioritizes issues based on timeframe to implement, ease of implementation, and overall impact.
- Samples encounters that have received either a clinical or billing denial related to case management type denials (e.g., referral, pre-authorization, medical necessity, non-covered service, etc.) and validates the denial reason.
- Assists with developing and maintaining performance tools for ongoing reports and acts as a liaison to the utilization management committee. Identifies and escalates consistent issues/trends with payers to AH leadership.
- Keeps a pulse on any regulatory changes and payer policies that may affect Adventist Health. Maintains confidentiality of information in compliance with hospital policies and HIPAA.
- Performs other job-related duties as assigned.
Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.
Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.
Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.
Other facts
About Adventist Health
Adventist Health Central Coast (formerly Tenet Health Central Coast) is proud to serve the Central Coast of California. We offer care through two acute care hospitals, two imaging centers and an expansive primary and specialty care network.
What you'll do
- The Care Management Analyst reviews patient encounters and medical records to identify improvement opportunities and supports strategic initiatives related to clinical reviews and denial management. They analyze and report findings to leadership while collaborating with various departments to streamline processes.
Ready to join Adventist Health?
Take the next step in your career journey