Position Summary:

Responsible for supporting and directing all levels of appeal to include closed chart appeals, reviewing and aggregating denial/appeals data, support of the Utilization Management (UM) staff, and to directly follow up with Payors regarding systemic trends in the data to ensure the best possible care for all patients in the system of care.

Position Responsibilities:

Clinical / Technical Skills (40% of performance review)

• Responsible for supporting and directing all closed chart appeals
• Coordinating and supporting all UM staff to ensure every denial is actively worked and diligently tracked throughout the Appeal Process.
• Actively process/work/follow-up on appeals for the hospitals
• Ensure Appeals are completed timely due to deadlines requirements
• Aggregate denial data and direct/support hospital denial management efforts through support of the UM staff.
• Directly follow up with Payors regarding systemic trends in the data.
• Review and update Denial Logs
• Documents in HCS the results of the appeals.
• Aggregates and manages the data for timely retroactive reviews and appeals
• Strong knowledge of external review organizations (i.e.: Medicare/Managed Care/Medicaid)
• Perform other duties as assigned

Safety (15% of performance review)

• Strives to create a safe, healing environment for patients and family members
• Follows all safety rules while on the job.
• Reports near misses, as well as errors and accidents promptly.
• Corrects minor safety hazards.
• Communicates with peers and management regarding any hazards identified in the workplace.
• Attends all required safety programs and understands responsibilities related to general, department, and job specific safety.
• Participates in quality projects, as assigned, and supports quality initiatives.
• Supports and maintains a culture of safety and quality.

Teamwork (15% of performance review)

• Works well with others in a spirit of teamwork and cooperation.
• Responds willingly to colleagues and serves as an active part of the hospital team.
• Builds collaborative relationships with patients, families, staff, and physicians.
• The ability to retrieve, communicate, and present data and information both verbally and in writing as required
• Demonstrates listening skills and the ability to express or exchange ideas by means of the spoken and written word.
• Demonstrates adequate skills in all forms of communication.
• Adheres to the Standards of Behavior

Integrity (15% of performance review)

• Strives to always do the right thing for the patient, coworkers, and the hospital
• Adheres to established standards, policies, procedures, protocols, and laws.
• Applies the Mission and Values of SUN Behavioral Health to personal practice and commits to service excellence.
• Supports and demonstrates fiscal responsibility through supply usage, ordering of supplies, and conservation of facility resources.
• Completes required trainings within defined time periods, as established by job description, policies, or hospital leadership
• Exemplifies professionalism through good attendance and positive attitude, at all times.
• Maintains confidentiality of patient and staff information, following HIPAA and other privacy laws.
• Ensures proper documentation in all position activities, following federal and state guidelines.

Compassion (15% of performance review)

• Demonstrates accountability for ensuring the highest quality patient care for patients.
• Willingness to be accepting of those in need, and to extend a helping hand
• Desire to go above and beyond for others
• Understanding and accepting of cultural diversity and differences

Education:

• Required: Graduate from an Accredited School of Nursing, Associate of Nursing, or Associates degree or Bachelors degree in Health Care Administration, Health Information Management
• Maintains education and development appropriate for position.
• May substitute relevant experience for education

Experience

• Required: One year of experience in a behavioral healthcare setting, experience with appeal process.
• Preferred: 3 5 years clinical nursing experience, or 1 3 years Managed Care experience in the specific program supported by the plan such as Utilization Review, Medical Claims Review, Long Term Services and Support
• May substitute relevant education for experience