Shriners Children's

• Reports to the Revenue Cycle Manager and supports regional revenue cycle operations for California locations through advanced data analysis, denial trending, performance reporting, and targeted resolution of complex pre-bill edits. • Identifying root causes of claim barriers, quantifying financial impact, and delivering actionable insights that improve clean claim rates, reduce denials, and optimize net revenue performance. • Operating with a high degree of independence under the strategic direction of the Revenue Cycle Manager. • Partners closely with Patient Access, Practice Managers, Contact Center leadership, clinical departments, and external vendors to support data-driven process improvements and enterprise-wide denial prevention strategies. • Serves as a key analytical resource, translating performance data into operational recommendations that align with regional and system revenue cycle goals. • Lead advanced analysis of denials, pre-bill edits, and payer trends to identify systemic issues and quantify financial impact. • Partner with Revenue Cycle Manager to prioritize initiatives based on risk exposure, revenue opportunity, and operational performance gaps. • Conduct comprehensive root cause analysis and lead the development and monitoring of corrective action plans to prevent recurring denials and claim edits. • Present findings and strategic recommendations to leadership, translating complex analytics into clear operational direction. • Drive data-informed process redesign and denial prevention strategies.

• Interpret health record documentation using knowledge of anatomy, physiology, clinical disease processes, pharmacology and medical terminology to identify diagnoses and procedures. • Assign and sequence all ICD-10; CPT 4; Healthcare Common Procedure Coding (HCPC) and modifier codes for services rendered accurately and completely. • Reconcile correct coding edits and discrepancies prior to final coding. • Maintain coding quality of 95% or higher while meeting established productivity requirements based on encounter type. • Follows coding guidelines and legal requirements to ensure compliance with federal and state regulations. • Identify trends in documentation deficiencies and communicates areas of improvement opportunities to leadership and/or providers. • Acts as a key liaison for the physicians and clinical staff as it relates to coding and compliance. • Interacts with physicians and other professional staff of documentation issues relating to coding data. • Must be able to work independently with minimal supervision.

Role Description The Outside Services Coordinator is responsible for coordinating and facilitating patient services that are performed outside the four walls of the primary care site. This role ensures that medically necessary external services—such as advanced diagnostic imaging, specialty testing, or ancillary services—are authorized, scheduled as appropriate, and aligned with the patient’s overall plan of care. The Outside Services Coordinator serves as a key liaison among patients, providers, payers, and external service vendors to support timely access to care. This includes: - Obtaining prior authorizations - Communicating medical necessity requirements - Assisting with appointment scheduling when necessary - Coordinating external service dates with facility-based visits to promote continuity, efficiency, and a positive patient experience Responsibilities - Obtain and manage prior authorizations and approvals from payers for advanced imaging and other services performed by outside providers, ensuring compliance with payer and regulatory requirements. - Coordinate referrals and service requests with external vendors (e.g., imaging centers, specialty clinics, diagnostic facilities). - Assist patients with scheduling outside services when applicable, including providing instructions, preparation requirements, and location details. - Align external service appointments with scheduled hospital visits or procedures to minimize delays, duplicate testing, and patient burden. - Communicate authorization status, scheduling details, and test requirements to patients, providers, and care teams. - Track authorization timelines, denials, and expirations; initiate follow-up actions and appeals as needed. - Maintain accurate documentation in the electronic health record and related tracking systems. - Identify and address barriers to care, including scheduling challenges, insurance coverage issues, or vendor availability. - Collaborate with internal departments (clinical teams, case management, revenue cycle, scheduling) to support seamless care transitions. This is not an all-inclusive list of this job’s responsibilities. The incumbent may be required to perform other related duties and participate in special projects as assigned. Qualifications - 3 or more years of experience working as an authorization representative in an acute care hospital, physician practice or other healthcare setting - Epic EMR experience - High School Diploma / GED Preferred - Pediatric experience Benefits - Medical coverage on the first day of employment - 403(b) and Roth 403(b) Retirement Saving Plan with matching contributions of up to 6% after one year of service - Paid time off for full-time and part-time employees (40+ hours per pay period) - Life insurance - Short term and long-term disability - Flexible Spending Account (FSA) plans - Health Savings Account (HSA) if a High Deductible Health Plan (HDHP) is elected - Tuition reimbursement - Home & auto insurance - Hospitalization and critical illness insurance - Pet insurance - Coverage available to employees and their qualified dependents in accordance with the plans - Benefits may vary based on state law

Role Description As part of the Shriners Children's (SC) Department of Corporate Credentialing, this position is responsible for coordinating, monitoring, and maintaining provider enrollment and re-enrollment for physician/advanced practice professional providers' participation in all third-party and government insurance with which SC sites participate. Continuously exemplifies the mission, vision, values, and customer service philosophy of SC in job performance and in service to other persons outside of and throughout the organization. Responsibilities - Manages the completion and submission of provider applications for enrollment in all commercial insurance and Medicaid Managed Care plans for multiple locations in the SC system. - Tracks and maintains enrollments through timely re-validations. - Follows strict guidelines to protect providers’ information and maintain confidentiality. - Works closely with the insurance enrollment departments to discern specific enrollment requirements including pre-requisites, forms, documentation, and timelines. - Establishes relationships at the health plans necessary to promote swift enrollment turnaround time. - Performs follow-up with insurance payers via phone, email, fax, or website to resolve provider enrollment issues. - Negotiates to overcome roadblocks. - Collaborates with Health Plan Liaisons to address unresponsive health plans or streamline enrollment processes. - Maintains accurate records of enrollment activities in OnBase, including but not limited to, maintaining enrollment data, documenting activities through notes, tracking progress on enrollment worksheets, uploading enrollment-related documentation and communications. - Establishes providers’ CAQH (Council for Affordable Quality Healthcare) profiles and maintains them up to date, uploading documents as required, and re-attesting profiles every 120 days. - Maintains MCC (Minnesota Credentialing Collaborative) profiles for providers at our Minnesota location, if applicable. - Coordinates with hospital staff to obtain provider signatures and additional data necessary for enrollments. - Establishes and maintains positive relationships with staff, both at the hospitals and Headquarters. - Prioritizes workload to promote hospital revenue goals and support Network Management contracting efforts as needed. - Point of contact for hospitals and HQ personnel for questions relating to enrollment with Commercial Insurance and Medicaid Managed Care plans. - Addresses inquiries in a timely manner, includes appropriate personnel, and escalates issues as appropriate. - This is not an all-inclusive list of this job’s responsibilities. The incumbent may be required to perform other related duties and participate in special projects as assigned. Qualifications - Minimum 1 year of credentialing or provider enrollment experience - Expertise with Adobe Pro and MS Office - High School Diploma/GED - Preferred Medicare, State Medicaid, and third-party practitioner enrollment experience - CAQH, MD-Staff credentialing database, or other credentialing/enrollment databases - Associate's degree Benefits - All employees are eligible for medical coverage on their first day. - Upon hire, all employees are eligible for a 403(b) and Roth 403(b) Retirement Saving Plan with matching contributions of up to 6% after one year of service. - Employees in a FT or PT status (40+ hours per pay period) will also be eligible for paid time off, life insurance, short-term and long-term disability, and Flexible Spending Account (FSA) plans. - Health Savings Account (HSA) available if a High Deductible Health Plan (HDHP) is elected. - Additional benefits for FT and PT employees include tuition reimbursement, home & auto, hospitalization, critical illness, pet insurance, and more. - Coverage is available to employees and their qualified dependents in accordance with the plans. Benefits may vary based on state law. Company Description Shriners Children’s is an organization that respects, supports, and values each other. Named as the 2025 best mid-sized employer by Forbes, we are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact. We foster a learning environment that values evidence-based practice, experience, innovation, and critical thinking. Our compassion, integrity, accountability, and resilience define us as leaders in pediatric specialty care for our children and their families.

• Analyzing denials data, creating metrics, tracking and trending denials and results for the Central Auth Unit • Performing appeals, correcting bill hold edits, identifying and trending root causes • Reporting out findings, assisting in mapping out process improvement opportunities • Coordinating payor denials and audit activities for timely response • Communicating and coordinating with various individuals/distributions related to CAU claims denials and edits • Participating in internal and SHC system-wide revenue cycle meetings to improve processes • Analyzing KPI data and coordinating revenue cycle analytics for the CAU

• Systematic review of anesthesia records to ensure accuracy, completeness, and compliance with regulatory and institutional standards • Verifying that all required documentation, provider signatures, and charges are present and appropriately supported • Supporting quality assurance and regulatory compliance within the anesthesia department • Assisting with other auditor duties as assigned • Monitoring, tracking, and reporting recurring errors or documentation trends to providers for process improvement initiatives • Collaborating with billing, compliance, and clinical departments to address documentation, regulatory, and process-related needs • Conducting detailed audits to ensure all charges are captured, supported by orders, and appropriately documented

• Analyzing denials data and creating payor metrics • Tracking and trending denials and results from multiple systems • Identifying and trending root causes and reporting out findings • Assisting in mapping out process improvement opportunities • Coordinating payor denials and audit activities for timely processing • Communicating and coordinating with various individuals/distributions • Monitoring day-to-day activities related to claims denials and audit reviews • Maintaining healthcare tracking tool/application • Supporting projects and initiatives of the Denials Management Team

• Managing all professional billing requirements • Managing accounts receivable tasks according to standard and productivity measurements. • Ensuring all regulatory and payor guidelines are followed. • Coordinating payor denial and appeal follow up activities to ensure timely response from third party payors. • Processing all payor denials, documentation requests and appeals. • Reviewing all denial accounts for categorization and special requirements for initiating appeals. • Communicating global payer issues with the payer relations team. • Assisting with monitoring of the day-to-day activities related to appeal follow up and denials. • Maintaining the healthcare tracking tool/application. • Monitoring all Claim Edit and Denial Management work queues and lists. • Ensuring medical records requests are completed and submitted within 48 hours. • Tracking all denials on a database to determine the outcome. • Collecting/analyzing, report status, metrics and trends of activity. • Distributing reports on a routine basis to specific distribution group. • Organizing all data and activity in a retrievable way.

Role Description The Denials Management Appeals Nurse (Anesthesia) is responsible for managing our medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Denials Management Appeals Nurse (Anesthesia) will utilize their clinical background to address the clinical denials, as well as write sound, compelling factual arguments for appealing denials. The Denials Management Appeals Nurse (Anesthesia) is also responsible for maintaining a detailed knowledge of Third Party Payors and Governmental Payors clinical/medical necessity criteria, as well as filing compliant appeals in accordance with Third party and governmental contracts. - Performs a review of assigned cases comparing the bill to the medical record. - Performs a detailed comparison of charges to documentation to ensure services documented have been captured through the charge process. - Performs a detailed comparison of charges to documentation to ensure services not documented are not charged. - Reviews documentation to ensure that services typically performed with specific procedures are being documented so that charge capture may occur. - Review findings with the hospital representatives and obtains an agreement on the discrepancies. - Demonstrates tact and understanding in handling problems, has a good rapport with hospital and corporate staffs. - Follows up on appeals in a timely fashion to ensure that cases are completed. - Re-checks mathematical computations before finalizing letter and report. - Updates status of all cases assigned on minimum weekly basis. - Informs supervisor of any changes, problems, or concerns that arise at a facility. - In the event of a dispute with the requesting party’s audit findings, files an appeal with the third party or governmental payor. - Analyzes and interprets all medical necessity/clinical denials from third party payors or governmental payors. - Files appeals based on medical documentation and interpretation of medical necessity guidelines or InterQual criteria. This is not an all-inclusive list of this job’s responsibilities. The incumbent may be required to perform other related duties and participate in special projects as assigned. Qualifications - 5 years of clinical healthcare/hospital experience - 3 years of related Anesthesia experience - Third Party Payor Appeals/Revenue Cycle experience - Current RN license in State of employment - Working experience with Utilization Review activities and general knowledge of TJC, PRO, and other regulatory bodies. Requirements - Bachelor’s degree - BSN highly desired - Case Management certification - Experience reviewing hospital and professional claims, denials and EOB's, appealing claims and working on claims in an audit - Experience with Epic, Craneware, Waystar, software and applications Benefits - All employees are eligible for medical coverage on their first day. - Upon hire, all employees are eligible for a 403(b) and Roth 403(b) Retirement Saving Plan with matching contributions of up to 6% after one year of service. - Employees in a FT or PT status (40+ hours per pay period) will also be eligible for paid time off, life insurance, short term and long-term disability, and the Flexible Spending Account (FSA) plans and a Health Savings Account (HSA) if a High Deductible Health Plan (HDHP) is elected. - Additional benefits available to FT and PT employees include tuition reimbursement, home & auto, hospitalization, critical illness, pet insurance, and much more! - Coverage is available to employees and their qualified dependents in accordance with the plans. Benefits may vary based on state law.

• Develops and systematizes current practice with standardized outcome measurements in therapy for core clinical pathways • Collaborates with Shriners Children’s Medical Group for guidelines and protocol development for seamless patient care transitions through multiple venues of care • Leads rehabilitation and therapy services departments in outcome usage specific to patient diagnoses • Evaluates, implements, standardizes, and monitors outcomes for specialized growth programs within rehabilitation and therapy departments • Develops location staff by way of facilitating and developing meaningful programs (clinical advancement, professional development, skill acquisition, etc.) • Develop and coach location leaders in contributing to departmental and programmatic growth to meet organizational objectives