Job Posting: Job Summary: Key job responsibilities and duties Under the direction of the Manager, the Supervisor is responsible for overall management and communication of clinically based appeals between Cedars-Sinai and outside payers. The Supervisor will also act as a liaison and point of contact to/for division and other internal representatives for denial and appeal inquiries. In addition the Supervisor will actively manage, maintain and communicate to appropriate stakeholders denial and appeal activities, trends, and recommended corrective action plans. Supports research, participates in strategic planning, both long and short term, and assures patient advocacy. Essential Functions List the essential functions in order of most significance.
Supports Manager in the response process for the organization on all government audits. Writes reviews and ensures responses are thorough and delivered timely. These include responses to all applicable entities.
Identification and facilitation of educational opportunities with other departments, providers, and payers to decrease denials and improve quality of service to patients. Conduct informal and formal education programs within the organization
Works in collaboration with other departments and health plans to develop corrective action plans to address identified trends in reasons for denials.
Supervises unit employees; including responsibility for determining qualifications, hiring, terminations, performance management, salary, assigning work, maintaining and improving competence, coaching, training, orientation, in-service and continuing education.
Reviews all denials and determines appropriates of denial based upon applicable guidelines, professional judgment, and/or community standards.
Utilizes electronic data base to track reason for denial, result of denial review as it relates to ability to appeal, date of appeal actions, outcome of appeal if appropriate.
Completes retrospective Utilization Review on patients whose admit and discharge time frames did not allow for concurrent Utilization Review as cases are identified.
Identifies contact on payer side for receiving Utilization Review information as able and communicates Utilization Review information in a timely manner to avoid denial for lack of clinical information.
Performs case management review of issues related to compliance with government payer coverage issues as well as commercial denials.
Provides oversight of the patient classification programs including but not limited to the pre-procedure review program and applicable vendors, and engagement.
Qualification Requirements/Preferences: Education Certifications/Licensure Experience Physical Abilities Educational Requirements: BSN License/Certification/Registration Requirements: CA RN License Upon Hire Experience: 2+ years of experience in case management in an acute care setting
Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scien...tists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical research and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major teaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competitive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.