The Director, Medical Review will: Lead tracking and coordination of all direct bill therapy appeals, ensuring thorough data compilation and analysis. Lead ALJ hearing preparation and maintain professional communication with facility and corporate personnel. Communicate effectively with public and medical personnel promoting clinical excellence. Uphold exceptional customer service standards, fostering positive relationships. Track audit topics and trends for process improvement and participate in or lead presentations/trainings. Responsible for thorough appeal preparation and submission, and to remain adaptable to evolving responsibilities.
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Reports To : SVP of Clinical Strategies and Consulting
Supervises : Medical Review Specialists, as needed.
Salary Range: $75-$85K
Principal Responsibilities and Duties :
The following is a list of specific duties, which are considered to be essential functions of this job. The list is not exhaustive as all duties are subject to change. This is consistent with our need to be flexible and responsive to the needs of our customers, patients, co-workers and associated policies. The employee who occupies this position is expected to assume any/all duties assigned by management, irrespective of whether such duties are specifically included in this list. While an effort has been made to thoroughly describe the customary manner in which this job is performed, reasonable accommodation will be made upon notification for qualified individuals with disabilities who may not be able to perform the job in the manner indicated.
Take the lead in tracking and coordinating all direct bill therapy appeals, overseeing the compilation and analysis of crucial data. Prepare personalized appeal letters for each denied claim, addressing issues like lack of medical necessity or coding errors. Review and refine documentation packets to ensure accurate representation of services being appealed. Ensure the accuracy of information within EMR/tracking systems, verifying that appeals are processed at the correct level and that dollar amounts are entered accurately. Collaborate closely with compliance and billing teams to streamline denials/appeals processing and ensure timely submission of completed appeals. Coordinate completion of required SL clinical claim corrections for billing between AGS, Rev Cycle, RVP and RD Work in conjunction with PMs and clinicians to initiate and oversee ALJ hearing preparation when necessary. Maintain professional and effective communication with personnel at both facility and corporate levels, supporting the denials-appeals processes. Engage in effective communication with both public and medical personnel as required, conveying information about denials, our care philosophy, and the therapy services provided by HPH. Uphold and promote HPH's commitment to exceptional customer service, fostering positive relationships with facility staff, company personnel, and fellow members of the therapy team. Track and analyze audit topics by MAC/State/OIG, contributing insights to improve processes and compliance. Lead or participate in presentations and trainings related to denials and appeals. Responsible for the thorough preparation and submission of appeals. Remain adaptable and responsive to evolving job duties and responsibilities. HIPAA & THE MINIMUM NECESSARY STANDARD :
The Employee shall maintain the confidentiality of all protected health information (PHI) whether electronic, written or oral to which he/she may be exposed either during the course of their duties or the result of an incidental disclosure. In accordance with the minimum necessary standard, the employee may only access PHI to perform the job as a Appeals Specialist. The minimum necessary standard must be applied in all matters and shall continue privacy protection during non-working hours and after employment is no longer with the company.
This job description does not list all the duties of the job. You may be asked by the supervisors or managers to perform other duties. You will be evaluated in part based upon your performance of the tasks listed in this job description.
Knowledge, Skills and Experience Required :
Must have exceptional organization and communication skills, ability to prioritize, effectively communicate and execute timely, all tasks related to the denials process. Self-motivated and disciplined with the ability to work remotely. Must be knowledgeable of the general interpretation of remittance advice from Medicare Administrative Contractors and terminology related to Medicare and other payor denials. Must demonstrate the ability to manually enter information into therapy EMR and extract information as directed by QAC, RD, RVP. Fundamental working knowledge of denials and appeals process. Proficient knowledge in Microsoft office (word, excel), Smartsheet, Adobe PDF, job-related internet research. Comfortable with computer and software utilization and expedient in grasping new software applications. 4 years post high school education in a therapy discipline preferred. Familiarity with medical terminology. Must be able to communicate effectively with internal and external customers; facility staff, HPH field management, corporate partners, etc. Physical Demands: Someone performing these duties should be in good physical condition and possess the capabilities, with or without reasonable accommodations.
Must be able to talk or hear and use hands to touch, handle or feel Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus Use of body mechanics and techniques for bearing weight Ability to sit for extended periods of time Ability to work on computer for extended periods of time
