Manager, Clinical Revenue Cycle

Cottage Health seeks a Manager, Clinical Revenue Cycle for their Clinical Denials and Appeals department responsible for the overall management of utilization review processes and clinical denials between Cottage Health and outside payers. The manager is also responsible for processes associated with patient status (inpatient / outpatient) within Cottage Health. This individual serves as a liaison and point of contact for all patient status and clinical appeal inquiries. Responsibilities include :

• The manager's primary responsibility is to oversee utilization review functions and to ensure accurate patient status throughout the health system. This includes but is not limited to accurate patient statusing, building the EMR to foster a successful UR program, working with physicians to ensure patient status, working with EMR tools to assist with patient status determination, providing continuous education to clinical providers and staff.
• The manager actively manages, maintains and communicates clinical denials and appeals activity to appropriate stakeholders. This includes, but is not limited to, the compilation of management reports such as : 1) denials in progress, 2) wins / partial wins / losses, 3) cases where Cottage Health has elected not to appeal based on chart documentation / support, and 4) identified cases pending review.
• Concurrent with these activities, the manager will identify and report on the categorization of denials, suspected or emerging trends related to payer denials and / or slow payment, and lead action planning for correction and process changes to eliminate avoidable denials.
• The manager will actively collaborate with clinical and / or administrative department leaders / physicians throughout the organization to educate on current denials trends, prevention, issues related to utilization review or patient status.
• The manager will assist the director of revenue cycle operations in providing clinical insights to problems and solutions facing the revenue cycle department. As an active member of the Utilization Review Committee, the manager will regularly report on outcomes of utilization review, denials and appeals.
• The manager will also coordinate, monitor, implement, manage and report back on educational activities for performance improvement. QUALIFICATIONS : All job qualifications listed indicate the minimum level necessary to perform this job proficiently. Education :
• Minimum : Bachelor's degree. Certifications, Licenses, Registrations :
• Minimum : Current nursing license in good standing. If not an active California nursing license, would need to become certified in California upon hire.
• Preferred : Milliman Care Guidelines Certification. Technical Requirements :
• Minimum : Must be able to demonstrate an understanding of InterQual and Milliman guidelines, community standards relevant to inpatient acute care. Must be able to exercise independent discretion and judgement, and act at all times with the highest degree of professionalism and objectivity. 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 various spreadsheet applications, including Microsoft Word.
• Preferred : Knowledge of revenue cycle functions and processes. Years of Related Work Experience :
• Minimum : 3 years of experience working with utilization review or case management in an acute care facility or health system. 2 years supervisory experience, which can be part of the 3 years in UR noted above.
• Preferred : 2 years direct patient care experience as an RN in an acute care setting. Cottage Health is a leading acute care hospital system, located on the central coast of California, widely known for our superior patient care, innovation, medical research and education. Our health system operates primarily in Santa Barbara, Ca, since 1888, and consists of three acute care hospitals, a Rehabilitation Hospital, multiple clinics and a multi-site Urgent Care system. Our mission is to serve the central coast communities with excellence, integrity, and compassion. Every day we touch thousands of lives in many different ways, resolute in our mission to put patients first. We take pride in helping our patients get back to living their lives - in the places they love. Cottage Health is an Equal Opportunity Employer. Cottage Health applicants are considered solely based on their qualifications, without regard to race, color, ethnicity, religion, age, gender, transgender, gender expression and identity, national origin, ancestry, disability, sexual orientation, marital status, military status or any other classification protected by law. This policy applies to all aspects of the relationship between Cottage Health and an applicant or employee. Cottage Health is committed to upholding discrimination-free hiring practices. We strive to cultivate an environment where exceptional people bring diverse perspectives and find belonging, support and connection to their work. Any Cottage Health applicants who require assistance or reasonable accommodations during the application process may request the need for accommodation with the Recruiter. If you're already a Cottage Health employee, please apply on this link only. Clinical Denials and Appeals, Full Time, 8 hour, Days, Cottage Health