1Lead AHS clinical denial prevention and management initiatives to support appropriate level of care Works closely with AHS revenue cycle leaders to complete current state assessment evaluate and implement leading practices for system standards andor local market programs needed Evaluates clinical denials and appeals data documentation and workflows to identify and address process and performance gaps2Lead successful denials prevention and performance improvement for AHS hospitals Monitors and manages AHS hospital performance to targets and leads corrective action plans needed to achieve organizational targets3Collaborates with Executive Director of Case Management to address barriers and gaps in utilization review and authorization confirmation services Provides hospitals with performance data analytics to make decisions and drive improvement Works with hospital and market leaders to identify when improvement plan is needed and follows up to ensure successful execution4Work with Managed Care Contracting to identify and address payer and Independent Review Organization IRO issues Collects and collates data from hospitals on payer issues and IRO results Provides AHS managed care leadership team with data to address issues with payers including avoidable days contract violations and process issues Provides input to contract language to support AHS case management service needs Participates with AHS Appeals with Physician Advisor in identifying and addressing trends with payor medical directors5Provide oversight for appeals assigned to the Physician Advisor PA and potential account downgrades Supports the development and implementation of clinical appeals workflow to incorporate AHS Appeals PA review prior to any account downgrade Works with Conifer and Tenet Appeals PA to identify opportunities for improvement including documentation and process Utilizes findings for process improvement and hospital PA and case management education Identifies trends to address with managed care contracting and plan medical directors6Uses tools to address performance barriers Develops and implements best practices to achieve organizational goals through effectively leading and managing change in a matrix environment Oversees the implementation of action plans and monitors progress toward goals assisting with addressing barriers and challenges and adjusting as needed in a supportive synergistic manner Collaborates with medical and nursing leadership as well as case management members to develop and implement methods to optimize use of hospital and postacute services7Manages multidisciplinary process improvement by utilizing excellent communication and servant leadership skills to challenge status quo and positively influence administrative teams and physicians to change processes to improve performance8Provides analysis and education regarding regulatory and clinical changes impacting inpatient and postacute care processes and reimbursement Provides education and tools for educating physicians and staff regarding programs and processesWorks in alignment with hospital and revenue cycle leadership teams and consistently demonstrates ability toConduct financial analysis develop business plans and secure approval for programsDevelop strategies to manage and prevent disputes and improve revenue cycle processesBuild trusting relationships with hospital and revenue leaders to successfully implement new programsBuild collaborative partnerships and lead cross functional teams to execute on plans and proposalsIdentify process inefficiencies via root cause analysis and design workflow to address opportunities identifiedDevelop and implement action plans managing follow up to achieve outcomesImplement targeted process changes including ongoing metric monitoring and management to achieve goals and drive improvement Supervisory ResponsibilitiesThe UR Nurses and Insurance specialist will report to this Central UR Manager
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