Supervisor

Job Title: Supervisor

Location: System Business Office

Department Name: Appeals

Req #: 0000216848

Status: Salaried

Shift: Day

Pay Range: $68,725.00 - $97,000.00 per year

Pay Transparency:

The above reflects the anticipated annual salary range for this position if hired to work in New Jersey.

The compensation offered to the candidate selected for the position will depend on several factors, including the candidate's educational background, skills and professional experience.

Job Overview:

The Supervisor is responsible for managing the clinical denials and works to resolve the denials and authorizations. They will collaborate with Case Management and Centralized Scheduling to ensure compliance pertaining to denial/appeal process with focus on obtaining optimal reimbursement. The Supervisor is primarily responsible for QA and Productivity review. Ensure the staff is properly appealing clinical and technical denials to ensure appeals are accurately pursued. In this role, you would be responsible for managing the process flow, and ongoing training.

Qualifications:

Required:

• HS diploma or GED equivalent
• Must possess a valid nursing license.
• Current & Valid RN/LPN/LVN licensure
• Must possess MCG UM Certification or obtain within 6 months of employment.
• Minimum of 5 years recent acute care experience with the last 2 years in a facility environment.
• Minimum of 2 years UR/UM/CM.
• Must have excellent interpersonal, oral, and written communication skills.
• Must have excellent organizational and time management skills.
• Strong project management skills and advanced problem solving and analytical skills.
• Knowledge in capturing, analyzing and communicating measurement results.
• Strong Microsoft Office skills, particularly Microsoft Excel.
• Ability to work well individually and in a team environment.

Preferred:

• Bachelor's Degree preferred
• Medical-surgical/critical care experience preferred.

Scheduling Requirements:

• Full-Time, Salaried position- 37.5 hours a week

Essential Functions:

• Demonstrates ability to critically think, problem solve and make independent decisions supporting workflow and appeal process.
• Must have proficiency with online nationally recognized UM criteria, including Milliman Care Guidelines and/or InterQual.

• Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required.
• Maintain and organize the workflow to ensure that denials are worked according to departmental policy and standards.

• Create action plans, process improvement and address gaps and opportunities for improvement from front end to back end.
• Maintain training documents.
• Create a systematic reporting mechanism monthly that analyzes denials, identifying changes and/or trends, and reports these to management.

• Identify all denial trends and provide education of steps to prevent future avoidable denials.
• Research payer denials related to referral, pre-authorization and medical necessity.
• Validate denial reasons and ensure denials reason is accurate and reflects the denial reasons codes.
• Generate an appeal based on the dispute reason and contract terms specific to the payer, this includes online reconsiderations.

• Follow specific payer guidelines for appeals submission.
• Escalate exhausted appeal efforts for resolution.
• Research contract terms/interpretation and compile necessary supporting documentation for appeals adjudication issues, and referral to refund unit on overpayments and recoupments.
• Work payer projects as directed.
• Develop and support effective working relationships among various departments for root cause analysis and resolutions.
• Reviews accounts and makes recommendations to management regarding non collectible accounts.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Benefits and Perks:

At RWJBarnabas Health, our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees' physical, emotional, social, and financial health.

• Paid Time Off (PTO)
• Medical and Prescription Drug Insurance
• Dental and Vision Insurance
• Retirement Plans
• Short & Long Term Disability
• Life & Accidental Death Insurance
• Tuition Reimbursement
• Health Care/Dependent Care Flexible Spending Accounts
• Wellness Programs
• Voluntary Benefits (e.g., Pet Insurance)
• Discounts Through our Partners such as NJ Devils, NJ PAC, Verizon, and more!

Choosing RWJBarnabas Health!

RWJBarnabas Health is the premier health care destination providing patient-centered, high-quality academic medicine in a compassionate and equitable manner, while delivering a best-in-class work experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time. As the leading academic health system in New Jersey, we advance innovative strategies in high-quality patient care, education, and research to address both the clinical and social determinants of health.

RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state. We understand the growing and evolving needs of residents in New Jersey-whether that be enhancing the coordination for treating complex health conditions or improving community health through local programs and education.

Equal Opportunity Employer