- Oversee in patient Medical necessity Denials for the network by managing and supporting direct/indirect reports including RNs, Administrative Assistant, and per diem DM Physician Advisors
- Review medical necessity denials to determine
- Write timely appeals based upon medical necessity using appropriate criteria (Milliman and/or InterQual , evidenced-based medicine for rationale and contracts.
- Appeal medical necessity TPA denials and write brief memorandums for ALJ tp present the case before ALJ.
- Maintain working relationship with payers via periodic discussions of medical necessity
- Maintain working relationship with various departments
- Implement CMS Form 1696 process to help mitigate MA medical necessity denials
- Maintain contact with CHA via the Payer Audit Representatives Meeting
- Pursue/follow up with State Insurance Commissioner and/or AHA ie, compile issues.
- Review of Medicare one-day length of stay cases for possible addendum (send to Assistant Hospitalist Director - DH)/for NH, review with JK in CM and recommend possible addendum; otherwise possible adjustment to provider liable
- Provide education to new Hospitalists upon employment re: UR processes (IP, OP, CC44), and DM processes (documentation, peer to peer and Yearly denial education to the Surgical
- Comprehensive review QIO short stay denials, give oral presentation to rebut the denials, followed by written appeals to MAC, QIC, ALJ as needed
- Minimum 5+ years of in-patient patient care experience
- MS Excel, Word, Presentation skills
- Knowledge base of Government (Federal/State) and Commercial payer policies, regulations, and contracts; knowledge base of medical necessity criteria;
- Board Certification and state licensure
- MD Degree / DO Degree accepted as well
- Experience in appeal writing and peer to peer discussions
- Ability to communicate effectively
- Significant manual skills / motor coord & finger dexterity
- Little or no potential for occupational risk
- Sedentary/light effort. May exert up to 10 lbs. force
- Generally pleasant working conditions.
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Medical Director Denial Management Nuvance Health - Danbury, United States - Danbury Health Systems
Description
Nuvance Health has a network of convenient hospital and outpatient locations - Danbury Hospital, New Milford Hospital, Norwalk Hospital and Sharon Hospital in Connecticut, and Northern Dutchess Hospital, Putnam Hospital Center and Vassar Brothers Medical Center in New York - plus multiple primary and specialty care physician practices locations, including The Heart Center, a leading provider of cardiology care.
Non-acute care is offered through various affiliates,Summary:
Management of Medical necessity Denials by root cause analysis and resolution for financial stability of the organization, provides a uniform structure, direction and education for optimum results and to achieve service excellence.
Responsibilities:
i. If the case is viable,
b. Attempt peer to peer if timeline allows or send written appeal
i. if lacking, downgrade to a lower level of care
c. Adjust level of care (eg, NICU levels, ICU levels)
d. Adjust days
e. Combine readmissions
b. Send beneficiary grievances
Periodically review CMS manual re:
MA plans and keep up to date with national commercial and CMS denial issues - RAC Relief, RAC summit, Modern Healthcare, Becker's, Medical Economics, Keckley Report, RAC Monitor, etc
Other information:
Location:
Summit-100 Reserve Rd
Work Type:
Full-Time
Standard Hours: 40.00
FTE:
Work Schedule:
Day 8
Work Shift: 8-4:30
Org Unit: 1768
Department:
Denial Mgmt
Exempt:
Yes
Grade:
P1
Salary Range:
Working conditions:
Essential:
We will endeavor to make a reasonable accommodation to the known physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation of our business.
