• Supervise, mentor, and develop a team of Clinical Appeals and Denials RNs.
• Conduct regular coaching sessions, performance reviews, and professional development planning.
• Monitor productivity, quality, and compliance metrics to ensure achievement of departmental goals.
• Facilitate team meetings, training sessions, and ongoing education initiatives.
• Manage staffing assignments, workload balancing, PTO coverage, and scheduling needs.
• Oversee the review and management of medical necessity, authorization, and clinical validation denials.
• Ensure timely preparation and submission of first-level, second-level, and external appeals.
• Guide staff in developing evidence-based appeal arguments utilizing clinical documentation, regulatory requirements, and nationally recognized guidelines such as InterQual and MCG.
• Review complex and high-dollar denials and provide escalation support as needed.
• Ensure all appeals meet payer-specific requirements and submission deadlines.
• Analyze denial trends and identify root causes impacting reimbursement.
• Collaborate with Revenue Cycle, Case Management, Utilization Review, CDI, HIM, and Operational Leadership to implement denial prevention strategies.
• Monitor recoveries, overturn rates, appeal success metrics, and financial outcomes.
• Develop action plans to address payer performance concerns and recurring denial patterns.
• Participate in client and leadership meetings to present denials performance and recommendations.
• Ensure adherence to organizational policies, regulatory requirements, and payer guidelines.
• Perform quality audits of appeal submissions and provide feedback to staff.
• Maintain expertise in CMS regulations, Medicare and Medicaid requirements, commercial payer policies, and industry best practices.
• Support audit readiness and compliance initiatives.
• Identify and implement process improvements that enhance efficiency, quality, and financial outcomes.
• Assist in developing standard operating procedures, workflows, and training materials.
• Utilize data analytics and reporting tools to monitor team effectiveness and operational performance.
• Support implementation of new clients, programs, and denial management initiatives.
