Manager, Clinical Denials & Appeals

Job Summary :

Manages and has oversight of clinical denials and appeals in all assigned markets. Ensures efficient and effective operations through highly engaged staff and providers and is an integral member of the leadership team, developing and executing key strategic initiatives that adheres to and follows the mission of Adventist Health, with a focus on driving clinical outcomes and improving collaboration between external vendor and external departments.

Manages the daily operations of the clinical denials and appeals in assigned markets and oversees the clinical denials specialists and assigned care management coordinators.

Plans and maintains operational budgets and staffing levels in coordination with the system operational director of utilization management and is responsible for the goals and financial performance of all assigned entities.

Accountable for the performance of revenue cycle outcomes in clinical denials and appeals. Participates, collaborates with, and supports the respective managers of the inpatient acute care management team and works with other healthcare professionals to provide quality patient care and maintains safety and educational needs.

Supervises and directs the various levels of assigned personnel and activities using both professional and supervisory direction as well as independent judgment.

Job Requirements :

Education and Work Experience :

• Bachelor of Science in Nursing (BSN) or equivalent combination of education / related experience : Required
• Five years' of experience in related denials and appeals : Preferred
• Five years' of experience in utilization management : Preferred
• Three years' of related healthcare administration and / or revenue cycle operational experience : Preferred
• One year leadership experience : Preferred

Licenses / Certifications :

Registered Nurse (RN) licensure in the state of practice : Required

Essential Functions :

• Reads, interprets, and delivers daily reporting metrics.
• Delegates daily work assignments and monitors the compliance of daily denial reviews and appeals.
• Responds to managed care denials in a timely manner.
• Works with external vendor on delegating cases requiring appeal.
• 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, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc.

as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.