Appeals Manager

Appeals Manager

The Appeals Manager is responsible to assist in the analysis and preparation of response to denial notification letters that arrive in letter and electronic format. Collaborating with the Department Denial and Appeals Coordinators, Physician Advisors, and the clinical staff, the Appeal Manager is responsible to develop a strong appeal letter that will result in the denial being overturned providing the hospital reimbursement for the care and services provided to the patient. The Denial Manager will assist the department's leadership develop strategies for denial prevention, improved utilization management, documentation of medical necessity and identify patterns and trends to prepare education programs for the staff on identified deficiencies to best respond to all hospital denials notification and documentation efforts. The Appeals Manager will provide timely tracking and trending of all denials and appeals, prepare weekly status reports, attend necessary meetings to assist the department attain its objective of managing denials and appeals.

Responsibilities

• Types, utilizing a keyboard, and edits a variety of material, frequently involving technical or specialized terminology; uses a mouse to navigate computer software programs and products.
• Processes and distributes mail, telephone and fax messages according to established procedures; prepares material for mailing by letter, fax, and / or electronic transmission as required and when applicable.
• Enters and updates information in electronic record systems and data bases; develops routine spreadsheets and databases; utilizes various software packages in performance of duties.
• Prepares and summarizes data and reports from a variety of sources in accordance with specific instructions or procedures.
• Maintains cordial telephone presence when interacting with business associates to exchange and obtain necessary Appeal Department information; documents all telephone communications in accordance with department procedures using Care Management and other resources, escalates issues related to business associate interactions and department staff when prevented from completing job tasks.
• Assists the Administrative Manager and Director with annual review and revisions of departmental policies, and procedures as required.
• Participates in special projects as determined by the Director.
• Assists in preparing and maintaining all the necessary documents and manuals to comply with regulatory and inspecting agencies such as IPRO, The Joint Commission, Regional and Medical Audit Contractors, and other licensing, accrediting, or review agencies.
• Keeps current on concepts, techniques, and methods relative to areas of responsibility.
• In conjunction with the Department's leadership team, helps build enthusiasm, stability, teamwork, and competence among employees through supervision, individualized evaluation and counseling, training and praise for a job well done.

Qualifications

The Appeal Manager must have excellent verbal and communication skills as a large part of the job requires telephone communication and interaction with healthcare agencies staff and medical directors, physicians, nurses, external agency executives and administrative leadership as well as hospital department leaders. The Appeal Manager should have excellent computer keyboard and mouse skills, be willing to learn electronic medical record systems and data entry into an electronic database system.

The Appeal Manager should be a nurse who has 3-5 years or more of experience in healthcare administrative management and services work. On the job or formal training in certified case management, denial and appeals management from a business school in office management, professional trade association, a closely related area is preferred.

The Appeal Manager should have experience as a nurse in acute care clinical setting who is able to providing guidance, direction and training to nurses, physicians, clerical and other clinical staff members.