Associate Director Clinical Appeals - Denial Management

Overview

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 54 hospitals and has more than 360 outpatient locations in 15 states providing more than 3.0million patient visits annually. It is one of the nation’s leading health systems with over 60,000 employees and physicians. Twenty-one of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team!

Responsibilities

The Associate Director of Clinical Appeals/Denial Management is responsible for the clinical appeals process under the Utilization review department. This position will provide leadership and oversight to the clinical appeals process for the assigned Region. The Associate Director will act as a strong advocate for proper reimbursement to hospitals in a changing health care environment and provide reports and education to the facilities for process improvement to prevent future clinical denials. The Associate Director is responsible for implementing consistent policies and practices across all facilities within the assigned region and developing monitoring tools to ensure processes are adhered to and meet regulatory compliance standards. The Associate Director will serve as liaison in Clinical Appeals for hospital and physician leaders. Perform other duties as assigned.

Qualifications

EDUCATION, EXPERIENCE, TRAINING

Required qualifications:

1. Medical/ Dental Graduate or RN with current valid license and relevant education.
2. Master of Public Health (MPH) or related master’s degree.
3. Minimum of 6 years of experience with Utilization review, Clinical appeals and denials process.
4. 4 years of supervisory experience in Utilization Management.
5. CRCR /CHFP certification

Preferred qualifications:

1. Knowledge of care delivery documentation systems and related medical record documents.
2. Strong broad-based clinical knowledge and understanding of pathology / physiology of disease processes.
3. Excellent written and verbal communication skills. Excellent critical thinking skills.
4. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff.
5. Working knowledge of inpatient admission criteria.
6. Ability to work independently in a time-oriented environment.
7. Computer literacy and familiarity with the operation of basic office equipment.
8. Assertive personality traits to facilitate ongoing physician communication.

Pay Transparency

Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $138,964.80 to $161,200.00 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.

Employment Status

Full Time

Shift

Days

Equal Employment Opportunity

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights:

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