Clinical Program Manager Appeals
- Job Title
- Clinical Program Manager Appeals
- Job ID
- Washington, DC 20060
- Other Location
With over 150 years of caring for our community and each other in the Washington DC area, Howard University Hospital has a world-renowned reputation for high-quality, patient-centric care. Howard University Hospital is the nation’s only teaching hospital located on the campus of a Historically Black University and has created a superior learning environment, with groundbreaking research and positive patient outcomes.
Howard University Hospital seeks to hire a Clinical Program Manager Appeals who will embrace our reach and historic tradition of excellence. If you want to make a difference in someone’s life every day, consider a position with a team of professionals who are doing just that, making a difference.
Under the general direction and guidance of HUH UR (Utilization Review leadership, the Clinical Program Manager, Appeals conducts retrospective chart reviews for clinical, financial, and resource utilization information. Composes appeals letters in an effort to overturn denial of payment for services rendered. Assist HUH UR leadership to develop corrective action plans for process improvement.
The Clinical Program Manager Appeals:
- Serve as Clinical Program Manager to actively provide quality oversight of payer recovery activities. Identifies and reports on the categorization of denials, suspected or emerging trends related to payer denials and/or slow payment, and coordinates with Utilization Review leadership to develop strategy for correction and process changes to eliminate avoidable denials.
- Research payer denials related to referral, pre-authorization, medical necessity, case management, non-covered services, and billing resulting in denials and delays in payment.
- Summit detailed, appeals to payers based on review of medical records and in accordance with Medicare, Medicaid and third-party guidelines as well as Howard University Hospital policies and procedures.
- Act as subject matter expert (SME) and accountable for oversight of clinical appeal activity. Achieve and maintain excellent clinical appeal outcomes and provide the support and guidance necessary to ensure the specified guidelines and outcomes are consistently exceeded.
- Assists HUH UR leadership with developing goals, objectives, policies, and procedures. Provides feedback to UR Leadership and staff on denial trends to promote quality and process improvement.
- Participates in evaluating staff; trains and orients staff; assists HUH UR leadership to develop corrective action plans for process improvement.
- Assumes other duties and responsibilities that are related and appropriate to the position and area. The above responsibilities are a general description of the level and nature of the work assigned to this classification and are not to be considered as all-inclusive.
- Promotes adherence to the Health Sciences Compliance Program, the Howard University Code of Ethics and the Health Sciences Standards of Conduct.
- Attends annual and periodic mandatory Compliance Program training including the Health Insurance Portability and Accountability Act (HIPAA) Privacy training.
- Participates in activities that promote adherence to federal healthcare program requirements.
- Actively participates in Health Sciences Compliance Program activities
- Adheres to the requirements of the HIPAA Privacy Policies and Procedures.
- Maintains confidentiality of patients, families, and staff.
Minimum Required Qualifications:
- Identify minimum competencies required to perform the job, including knowledge, skills, abilities, and other characteristics required of an employee to successfully perform the functions and duties of a job.
- List required competencies in order of importance to the job. If including “Preferred” competencies in addition to required, mark each as preferred and list them last.
- Knowledge of various spreadsheet applications, including Microsoft Word. Knowledge of billing requirements related to charges
- Demonstrate proficiency using evidence-based clinical decision support solutions (i.e. Interqual/MCG/CMS criteria and regulations) to make appropriate medical utilization decisions relevant to inpatient/outpatient acute care, and payer denial and appeal processes.
- Must be computer literate and able to manage Outlook, Word and Excel programs, prepare charts and graphs, and analyze data to identify trends and opportunities for process improvement.
- Knowledge of DRG, ICD and HCPCS coding highly desirable
- Knowledge of level of care requirements for inpatient, outpatient, observation and extended recovery
Education and Experience Qualifications:
Culture of Care Statement: In an effort to improve patient safety, Howard University Hospital (HUH) supports a Just Culture. This atmosphere of accountability promotes the identification of human error (mistake), at-risk behavior (behavioral choice that increases risk) and reckless behavior (disregard for risk). The goal is to maintain a culture for learning, safe systems and well managed behavioral choices.At Howard University Hospital, our job is to care for you. We do this by offering:
- Bachelor’s degree in Nursing required; Master’s degree preferred
- Two (2) years direct patient care experience as an RN in an acute care setting.
- Two years (2) of experience working with denials and appeals, utilization review, and case management in an acute care setting.
- One (1) year supervisory experience desired.
- Current Registered Nursing license in good standing. If not an active Washington, DC, nursing license would need to become certified in Washington, DC upon hire.
- Certification in case management, denial management or Nurse Practitioner preferred.
Work life balance
Recognition and rewards for professional expertise
Competitive, comprehensive benefit plans offered (including health, disability, vacation, sick leave, and 403B retirement plan)
Howard University Hospital requires all external applicants to be fully vaccinated for COVID-19 before commencing employment. External Applicants may be required to furnish proof of vaccination and, if offered, may elect to be vaccinated at a designated Howard University Hospital location.
- Required Skills