Job Information
Intermountain Health Government Appeals Manager in Denver, Colorado
Job Description:
Responsible for managing the daily operations of the Appeal and Audit Recovery teams in the RCO. This position coordinates strongly with legal, Physician Advisors, Care Managers/Utilization Review, Payor Contracting and clinical teams, bringing their knowledge together with her staff’s knowledge to create an Appeal Unit that recovers monies not paid by the insurance companies for care we have given. This position reports to the Director of Appeals.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Understands and educates staff about various contracts and laws (i.e., ERISA, self-funded, State and Federal insurance) to appropriately appeal medical claims that have been denied.
Conducts and assesses patient accounts when requested by payers, audit firms, patient and RCO departments to determine the appropriateness of billed charges, chargemaster data, revenue cycle data and UB/HCFA1500 information that is on the claim.
Understands and educates staff about the true reasons for the denial and looks at payer contracts, clinical data and other data to be able to appeal in a correct and concise way.
Assesses the appropriateness of clinical appeal requests by working with and using evidence based utilization review criteria, payer policies and Federal and State regulations. Works with Payor Contracting to ensure language within contracts best addresses clinical processes within Intermountain.
Refers and consults on appeal cases to the designated Physician Advisor and works with them for obtaining support for appeals.
Collaborates and educates Care Management, Physician Advisors, Revenue Integrity, Compliance, legal counsel, and RCO teams on how to present and prepare appeals.
Identifies trends and opportunities for denial prevention and collaborates and presents with the appropriate multidisciplinary teams to improve denial management, documentation, and appeals process. Presents data to clinical entities for process improvement.
Supports legal counsel on strategies to appeal and prepares staff for Administrative Law Judge hearings as part of the appeal process.
Serves as a subject matter expert, resource and mentor to others within the RCO, clinical departments, Appeal RN’s, legal, IPAS and Payor Contracting on the art of appealing.
Works with staff to become collaborative with clinical departments to ensure RCO and clinicians are working as a team to get accounts paid, using both sides knowledge.
EDUCATION
Required:
2+ years Revenue Cycle Experience with 2+ years Management Experience in Revenue Cycle
Preferred:
Bachelor’s degree (BSN) is preferred.
Physical Requirements:
Location:
Lake Park Building
Work City:
Work State:
Scheduled Weekly Hours:
40
The hourly range for this position is listed below. Actual hourly rate dependent upon experience.
We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.
Learn more about our comprehensive benefits package here (https://intermountainhealthcare.org/careers/benefits) .
Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.
All positions subject to close without notice.