Vice President of Clinical Appeals | PAM Health Corporate

Vice President Of Clinical Appeals

The Vice President of Clinical Appeals is responsible for providing leadership and is an active participant in the day to day operations of the department. This includes but is not limited to organization, development, and management of the department and its members.

Responsibilities

• Demonstrates proficiency in all skills required by the Vice President of Clinical Appeals with a focus on converting both commercial and MCA clinically appropriate patients from denied to authorized for admission.
• Directly trains and supervises the clinical appeals team to ensure compliance with all regulatory policies with a goal of overturning pre-admission denials.
• Acts as an active member of the appeals team performing comprehensive analytical reviews of clinical documentation to determine if an appeal is warranted.
• Prepares convincing appeal arguments using pre-existing criteria sets and / or clinical evidence from existing clinical references and / or regulatory arguments and prepares the response to payer in an effort to overturn the denial in a professional and concise manner.
• Prepares feedback and summaries of appeal activities by hospital to be included in the Monthly Operations Reports and Utilization Management Reports, as well as monthly reporting to the corporate team.
• Collaborates with the team and ensures adequate coverage for all responsibilities of the department.
• Assesses problem situations and after thorough investigation, plans and implements corrective action.
• Adheres to all policies and procedures.
• Identifies and solves problems in a timely manner. Gathers and analyzes information skillfully and develops alternative solutions.
• Demonstrates dependability including : following and giving instructions; responds to management direction; takes responsibility for own actions; keeps commitments; commits to long hours of work when necessary to reach goals; completes tasks on time or notifies appropriate person with an alternate plan.
• Demonstrates unquestionable integrity in every aspect of work and when dealing with others. Consistently models desired behaviors and values established by Post Acute Medical.
• Continuously manages administrative functions to ensure quality and timeliness. Manages accurate and timely activity and performance reports.
• Cooperates and collaborates for the good of co-workers, employees, and management. Encourages and fosters diversity. Treats others with dignity, fairness, and respect.
• Ensures compliance with HIPAA regulations, including confidentiality, as required.

Qualifications

Education and Training : Bachelors or Associates degree in nursing preferred. Knowledge in the area of LTAC and IRF Criteria including : Medicare, InterQual and Milliman are preferred. Currently licensed as an RN, preferred.

Experience : Five years' experience as a clinical nurse in an acute care setting. In addition, having at least two years of experience in appeals, case management, discharge planning and / or utilization review is preferred.

Knowledge, Skills, and Abilities : Will maintain current licensure while employed with Post Acute Medical.

About PAM Health

PAM HEALTH (PAM) based in Enola, Pennsylvania, provides specialty healthcare services through more than 80 locations, as well as wound clinics and outpatient physical therapy locations, in 17 states. PAM Health is committed to providing high-quality patient care and outstanding customer service, coupled with the loyalty and dedication of highly trained staff, to be the most trusted source for post-acute services in every community it serves. Its mission is to serve people by providing compassionate, expert care, and to support recovery through education and research. Joining our PAMily allows you to work in a collaborative environment with colleagues and leadership with exposure to a variety of patient care levels. Aside from our competitive pay, generous paid benefit time, and excellent insurance options, you will also have opportunities for professional growth through our Education Advancement Program. We are excited to learn more about you and hope that you consider joining us on a shared mission to improve the lives of others by being an integral part of our We Care Program.

PAM Health does not discriminate and does not permit discrimination, including, without limitation, bullying, abuse or harassment, on the basis of actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status, or based on association with another person on account of that person's actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status.