JOB SUMMARY

The Supervisor, Denial Resource Center provides direction regarding cases submitted to the Denial Resource Center (DRC) for clinical appeal. The Supervisor provides guidance to appeal writers and administrative assistants on daily workflow and ensures appropriate distribution of workload and cases.

ESSENTIAL FUNCTIONS OF THE ROLE

Supervises Denial Resource Center (DRC) RNs and Administrative Assistants through the monitoring of staff workload, developing staff assignments, and reviewing of productivity. Handles escalations from DRC RNs.

Conducts quality reviews, advises with peer-to-peer appeals and denial research.

Analyzes deadline report and worklists and assigns high priority, special cause accounts. Evaluates incoming cases for readiness for appeal and appropriate expertise assigned for appeal.

Recommends and implements quality improvement initiatives

Supports orientation of new staff and ongoing training

Reviews cases for appropriateness for referral for external appeal such as ALJ, THHSC, VA complaints. Writes clinical appeals, as needed.

Serves as a resource for staff related to complex accounts.

Interfaces with Collectors, Administrative Assistants and Appeal Writers to assess effectiveness of work processes and acts upon opportunities for improvement with account handoffs and communication regarding cases.

Serves as resource for IT and training on BSWH systems used in the DRC (e.g. Midas, AEOS, EPIC, Allscripts, PatCom, Nuance, Microsoft Office Suite, etc.).

Prepares reports as assigned for use within the department and external customers. This includes but is not limited to routine reports for verifying status of accounts using MIDAS, TRAC, AEOS.

KEY SUCCESS FACTORS

Understands commercial and government regulations for reimbursement including, but not limited to: InterQual, RAC/MAC, Clinical Policy Bulletins, national and local coverage determinations, CMS admission status requirements, TJC conditions of participation, CMS appeals process, including Administrative Law Judge.

Knowledge and understanding of nursing and patient care standards and procedures.

Knowledge of laws, rules and regulations; standards and guidelines of certifying and accrediting bodies; hospital and department/unit standards, protocols, policies and procedures governing the provision of nursing care applicable to the area of assignment.

Knowledge of medical terminology; principles and practices of health promotion, risk reduction, illness and disease prevention and management; medications and drugs, common dosages, their physical and physiological effects, and possible adverse reactions.

Knowledge of medical and professional nursing ethics and patient privacy rights.

Must be able to communicate thoughts clearly, both verbally and in writing.

Interpersonal skills to interact with a wide-range of constituencies.

Must have critical thinking and problem-solving skills.

Ability to observe changes in the medical condition of patients and effectively communicate these changes to other nursing staff members and physicians/providers.

Ability to provide age-specific, quality, patient-centered care to all patients through the nursing process and standards of nursing practice with sensitivity and respect for the diversity of human experience and to develop, evaluate, implement and, as necessary, modify a patient care plan to meet the needs of individual patients.

Ability to make tactical decisions around the allocation and direction of the work of supervised employees using established guidelines, policies and/or procedures.

Ability to make effective hiring and termination recommendations.

Ability to train and evaluate performance of supervised staff.

General computer skills, including but not limited to: Microsoft Office, information security, scheduling and payroll systems, electronic medical documentation, and email.

ACM or CCM license preferred.

BENEFITS

Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level

QUALIFICATIONS

- EDUCATION - Associate's

- MAJOR - Nursing

- EXPERIENCE - 3 Years of Experience

- CERTIFICATION/LICENSE/REGISTRATION -
       Registered Nurse (RN)