Director, Denial Prevention & Process Improvement

Job Purpose

The Director, Denial Prevention & Process Improvement leads the performance of deep dive analysis on clinical and technical denials for their respective client(s), utilizing multiple analytics tools and data sources to identify patterns and trends relative to medical necessity denials. The Denial Prevention Process Improvement Specialist applies high level problem-solving skills to perform root cause analysis on denied accounts to identify denial trends. Trends are then reviewed, and clients are guided through assessments of operations and preparation of policies, procedures, and tip sheets that assist in remedying the identified root causes. This position is client-facing and oversees completion of denial prevention committee reports and summaries for assigned client base, leads monthly denial prevention committee meetings, is the primary contact for assigned client(s) on medical necessity denial issues, establishes and maintains client relationships to drive best practice implementations, and utilizes sound judgment and experience to aggregate and advance team recommendations for correcting underlying issues impacting denials. Services are provided to client with internal understanding it is a supplement to and coordinated with the overarching goals of the Denial Management Team.

Duties and Responsibilities

• Provides relevant guidance and works to resolve issues identified through analysis of denial trends.
• Reviews individual denials to determine why they occurred.
• Professionally and effectively communicates with hospital contacts to recommend corrective and preventative actions and coordinates meetings and training sessions as necessary.
• Participates in Denial Prevention Task Force with assigned client leadership, covering necessary information relative to identified trends, progress from prior actions, and next steps.
• Establishing strong relationships with appropriate stakeholders/committee members, including Finance Leadership, Revenue Cycle, Managed Care, and hospital ancillary department heads
• Oversees documentation and trends prevention-related findings. Initiates or contributes to the creation of reports as needed with the goal of providing relevant management information for tracking and trending problems and measuring improvement against best practices benchmarks.
• Leads reviews using all patient accounting, host, Epic and related systems used across their client to verify and summarize trends concisely with suggested corrective action.
• Aggregates and provides strategic advisory perspective related to process improvement and quality in assessment of the root cause issues creating denials by working with the subject-matter experts and applicable owners to make recommendations to remedy process, system, and education issues.
• Utilizes materials and trains denial prevention staff, revenue cycle site directors, committee members, and revenue cycle staff as necessary on denials-related trends and issues impacting their client.
• Performs other duties as assigned
• Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards

Qualifications

• Bachelor’s Degree in Business or related discipline or work equivalency required
• Education in Healthcare Administration, Business or related discipline preferred
• 5+ years of experience in hospital revenue cycle roles with 2+ years of experience in a management position in hospital revenue cycle industry
• Certified Revenue Cycle Representative (CRCR) preferred
• Background and familiarity with various Hospital Accounting and EMR Systems
• Solid ability to analyze, interpret and present data in meaningful ways
• Project Work, Intermediate to Advanced Excel & Access Skills
• Project Management, Data Analytics skills

Working Conditions

• Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.
• Work Environment: The noise level in the work environment is usually minimal.

Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit-based factors, or any other characteristic protected by federal, state or local law.