Supervisor, Clinical Appeals
- Oakland, CA
- Highland General Hospital
- SYS Care Management
- Full Time - Day
- Req #: 26627-17630
- FTE: 1
- Posted: November 6, 2020
SUMMARY: Coordinates and executes the appeal process for all facilities clinical appeals and third-party audits, supervises Care Management Specialist workflow for referral, post hospital appointments and utilization management activities for inpatients.
DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.
1. Supervises staff and manages employee performance; provides on-going performance feedback, addresses problems, orients and trains employees, verifies competency and identifies and suggests way to develop skills; monitors workflow.
2. Supervises care management specialists with tasks to complete authorizations, follow up on hospital admission notification, tracking referrals, discharge appointments, sending clinical documentation to payors and support care management team to execute discharge planning.
3. Extracts, analyzes and presents authorization, referral , denial, avoidable days and compliance data for internal external stakeholders e.g. California Department of Health Care Services audits and reporting.
4. Oversees submission of audits for Care Management Specialists workflow, including but not limited to MediCal, Medicare and internal compliance studies.
5. Assists Manager with Administrative Day entry, Avoidable Day tracking, referrals place and close audits.
6. Assists Manager in establishing, implementing and ensuring that care management policies, practices and procedures are in accordance with the Joint Commission, Title 22 and other regulatory agencies and overall hospital policies.
7. Oversees requests for lower level of care authorizations, post-acute referrals, refers work queues for DME Home Health, SNF placement for timely entry, place and closeout.
8. Manages the appeal processes, until final resolution; coordinates and appeals clinical denials; develops appeal letters as well as input from the attending physician and/or Physician Advisor.
9. Identifies inappropriate admit status based on identified criteria for patient registration; Utilizes McKesson InterQual® clinical guidelines; refers questionable cases to the CM Manager or physician advisor for determination.
10. Collaborates and communicates with contracted Health Plans, Medical/Provider Groups, ancillary vendors, industry wide organizations (i.e. Department of Managed Health Care, Alameda County Health department, California Children’s Services), internal departments and any other providers when appropriate.
11. Tracks and trends progress and outcomes of denial and appeal processes and compiles reports for division and leadership.
12. Performs other duties as assigned.
Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.
Required Education: Graduate of an accredited nursing program.
Preferred Education: Bachelor’s degree in Nursing.
Required Experience: Five years of acute care nursing including medicine/surgery, ICU, telemetry or five years of Case Management experience in an acute setting or utilization review at a medical group or health plan.
Preferred Experience: Experience in a supervisory or lead role.
Required Licenses/Certifications: Valid license to practice as a Registered Nurse in the State of California; active BLS - Basic Life Support Certification issued by the American Heart Association;
Preferred Licenses/Certifications: Certification in Case Management, CCMC or ACM.