Director - Enterprise Denials Management

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Manages the enhancement and overall effectiveness of a centralized denials prevention and management group which minimizes revenue leakage for the revenue cycle. This position is responsible for implementing and maintaining enterprise level denials prevention and mitigation approach. Develops and controls all activities necessary to accomplish project and department requirements, including building relationships with internal and external clients throughout WVU Medicine, especially finance and clinical leadership. Utilizes internal resources and analytical skills to make decisions in fast-paced, fluid environment. Accountable for making decisions guided by organizational issues, trends, and business implications, keeping in mind that decision may have regional/local implications. Establishes new process improvement policies, functions, and objectives to best support the needs and success of the organization related to denials prevention.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s Degree in Healthcare, Finance, Business, or related field

EXPERIENCE:

1. Five (5) years of management experience

2. Five (5) years of experience in healthcare finance.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Master’s Degree in Business, Healthcare, or related.

2. Certified Healthcare Financial Professional (CHFP) of HFMA.

EXPERIENCE:

1. Seven (7) years of management experience in healthcare revenue operations, denials, coding, and reimbursement with experience developing standards, processes, policies and procedures for a diverse organization.

2. Record of success managing complex projects with multiple, diverse stakeholders.

3. Prior experience with Epic’s Hospital or Professional Billing module.

4. Experience working in an organization of size and complexity comparable to WVU Medicine.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. This position is responsible for directing and administering a centralized team of denial nurses, denial assistants, audit specialists, management and staff

2. The director will be responsible to lead and establish strategic initiatives around clinical medical necessity denials including new procedures, guidelines, and committees to support the mission of the department and stakeholders

3. This position will work closely with clinical, operational, utilization management, managed care, legal, and financial stakeholders to ensure we have a centralized denials prevention and management approach

4. Continually monitors and optimizes all aspects of denials and recoupment efforts including appeals.

5. Works with stakeholders in analyzing, trending, and identifying process improvement opportunities related to denials and mitigation, prevention and appeals related activity

6. Writes, interprets, adapts, and enforces Hospital and departmental policies as needed with management, employees, and customers.

7. Serves as representative of department and team within the organization. Integrates department operations into clinical hospital operations where needed and engages department leadership in any denials and appeal related activity.

8. Monitors annual operating and capital budgets for department, preventing and reporting variances where required.

9. Advises finance executives, Epic IT Team, and clinical departments of billing implications of operational decisions.

10. Prioritizes projects with management team. Work with management team to develop a project plan for implementation of process improvement projects and new partnerships with vendors, departments, and providers.

11. Maintain technical understanding and operational dependencies of system charging activities including charge generation, capture, routing, and billing and apply to risk and root cause analyses and recommendations.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to sit for extended periods of time.

2. Ability to lift, push or pull 10–15 pounds.

3. Visual acuity must be within normal range.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Office type environment.

2. Possible travel to other enterprise business sites.

SKILLS AND ABILITIES:

1. Organizational and professional skills; ability to lead large teams.

2. Oral and written communication; ability to effectively represent the department across all levels of the organization including executive leadership.

3. Ability to establish new partnerships and influence the work of others.

4. Knowledge of local, State and Federal regulations pertaining to Hospital billing, reimbursement and payment methodologies.

5. Ability to independently manage large-scale, multi-functional projects.

6. Advanced Knowledge of office software applications and Epic modules.

7. Excellent communication skills and creative thinking

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

661 SYSTEM Clinical Denial Management