Job Description

Location: Steward Health Care
Posted Date: 11/19/2021

KEY RESPONSIBILITIES:

  • Manages and advises the system on development and maintenance of an effective Audit and Appeals process.
  • Develops, implements, maintains, and reviews adequacy of Steward Audit and Appeal Team’s systems, policies, and functions to achieve stated goals, including, but not limited to appeal resolution and timely responsiveness.
  • Responsible for monitoring and evaluating performance measurement goals for the AAC Team, providing timely feedback and initiating corrective action or providing additional training and education as needed.
  • Recruits and retains, trains, manages, and evaluates staff.
  • Maximizes use of Steward Information systems (Allscripts, Meditech, PCON, etc.) to assure timely, effective data collection and reporting to Hospital CFOs, Hospital CMOs, and Steward Leadership.
  • Identifies and analyzes trends, suggest improvements, and provide education to hospitals and doctors as needed.
  • Requires a comprehensive knowledge of clinical documentation and medical coding, and a working knowledge of billing regulations/requirements and reimbursement.
  • Schedule as needed meetings with CFOs, CMOs, Directors of Case Management, and Department Heads.
  • Maintain professional competency, according to department policies, procedures, and protocols.
  • Maintain strict confidentiality and adheres to all HIPAA guidelines/regulations.
  • Other projects and duties as assigned.

REQUIRED KNOWLEDGE & SKILLS:

  • Knowledge of insurance state and federal regulations
  • Knowledge of the claims audit process
  • Outstanding leadership and interpersonal skills
  • Excellent written skills
  • Effective verbal communication

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

  • Education: Associate or Higher Degree
  • Experience (Type & Length): Five years’ experience in acute care setting; Three to five years’ experience in managed care environment/benefits management; Three to five years’ experience in Quality, Utilization Review, and/or Case Management
  • Certification/Licensure: Current license as a Registered Nurse
  • Software/Hardware: Computer knowledge and proficient in the use of Microsoft Office Applications especially Excel

Application Instructions

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