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RN Manager of Appeals/Denials

RN Manager of Appeals/Denials

Job Description

Job: Directors & Managers
The Manager of Appeals and Denials is primarily responsible for the analysis, coordination, monitoring, education and support to Case Management related to denials and appeals program. The Senior Manager of Appeals and Denials will work to ensure compliance with the appeals and denials processes throughout Case Management departments. The Senior Manager will track appeals and denials data, noting trends, performing root cause analysis and identifying improvement opportunities. This position will also facilitate process standardization to promote improved outcomes, maximize resource utilization, and improve organizational efficiencies. As an essential element to the overall success of the Case Management Program, the Senior Manager of Appeals and Denials consistently demonstrates a strong work ethic and commitment to excellence. This position requires the ability to function with minimal supervision, strong analytical and critical thing skills in Case Management and strong in a rapidly changing environment and to serve as a subject matter expert to the Case Management Department.

Job Requirements

• RN with current state licensure, BSN

• Strong clinical background with 3-5 years acute care nursing experience

• 3-5 years acute care case management experience required

• 2 years managerial experience

• Denials and Appeals Management experience required

• Analytical skill set necessary

• Competency with utilizing medical necessity criteria, InterQual training helpful

• In-depth knowledge of case management with a focus on utilization review practices

• Current working knowledge of non-governmental and government payers and contractual language

• Knowledge and understanding of CMS and TJC regulations and proficient with Excel and Microsoft Office Suite software

• Ability to communicate effectively in oral, written and electronic formats

• Ability to establish and maintain collaborative and effective working relationships with a focus on the importance of teamwork

• Demonstrates leadership skills which model analytical and critical thinking abilities, problem resolution, proactive decision-making, negotiation skills, consensus building, and effective resource utilization

Job Snapshot

Employment Type Full-Time
Job Type Nurse, Management, Health Care
Education 4 Year Degree
Experience Not Specified
Manages Others Not Specified
Industry Healthcare - Health Services
Required Travel Not Specified
Job ID 25086-5566
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RN Manager of Appeals/Denials

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