Shire Jobs

BrightSpring Health Services

Director of Clinical Denials Management and Audit supervises a team of RN/LPN clinical reviewers as well as Support staff managing all areas of clinical claim pre and post audit, appeals submission, and reporting to Palmetto in response to ADR's/TPE's/RCD processes across the enterprise HH and HO branches for all payor types striving to minimize lost revenue. Conducts analysis on denials and appeals and identifies trends that present process improvement and revenue protection opportunities. Monitors state and federal regulatory agencies to maintain up-to-date knowledge on changing rules and regulations affecting NCH denial prevention and management practice. Supports the development of standard operating procedures and plans, training, and ensure the denial department provides subject matter expertise around clinical denial management. This position will also support detailed level reporting and analytics, clinical appeals, root cause analysis, and address identified trends in reasons for denials. Work in partnership with HH & HO operations and customers to drive improvement in the quality of services delivered to patients.

* Audits patients records for quality and compliance per applicable home health regulations for submission for pre-claim review process of Review Choice Demonstration.
* Audits patients records for quality and compliance per applicable home health regulations for other projects per agency need including but not limited to improvement plans as part of targeted probe and educate surveys and patient safety surveys.
* Formulates and submits letters of appeal. Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines, evidence-based medicine, local and national medical management standards and protocols.
* Formalizes expert tracking of record reviews, recommendations back to the branches, revenue on hold due to audit, RCD submission and result percentages back and up through operations and revenue cycle.
* Analyzes information gathered by audits and reports finding and recommendations
* Tracks/trends audit result reporting results as requested
* Makes recommendations to leadership for training based on audit results.
* Acts as a resource and has expert knowledge of Medicare, Medicaid, and other applicable regulatory requirements.
* Provides consultation with clinical staff as needed to facilitate compliant documentation.
* Serves as a resource during accreditation and other survey activity.
* Travel to individual branches up to 20% per request
* Other duties as assigned.

* Requires a clinical background, degree in nursing, physical therapy, or occupational therapy from an accredited or approved school.
* Two years of experience in health care utilization review or home care.
* Two years prior home health or hospice experience required.

* Expert written and verbal communication skills
* Strong interpersonal skills
* Knowledge of the regulatory requirements at the state, federal, and local level
* Ability to prioritize tasks and manage multiple projects
* Strong analytical and problem-solving skills with attention to details
* Ability to utilize a personal computer and other office equipment.
* Proficient use of Electronic Medical Record software.
* Proficient use of Microsoft Office Suite-Excel, Word, and PowerPoint
* Solid ability to learn new technologies and possess the technical aptitude required to understand flow for data through systems as well as system interaction.