The University of Maryland Medical System is a 14-hospital system with academic, community and specialty medical services reaching every part of Maryland and beyond. UMMS is a national and regional referral center for trauma, cancer care, Neurocare, cardiac care, women's and children's health and physical rehabilitation.
UMMS is the fourth largest private employer in the Baltimore metropolitan area and one of the top 20 employers in the state of Maryland. No organization will give you the clinical variety, the support, or the opportunities for professional growth that you’ll enjoy as a member of our team. UMMS is currently seeking a Clinical Denial Manager for our Hunt Valley location.
***5 years in a patient care setting; 2 years Utilization Review/Quality Assurance/Case Management responsibilities is REQUIRED***
Under limited supervision, plans, organizes, coordinates, and manages the day-to-day operations of the Clinical Denial Team within Patient Financial Services Department, including developing policies, procedures, goals and methods to achieve these goals. Conducts utilization review on accounts post-discharge to secure appropriate reimbursement from payors for services rendered to their clients by UMMS. Composes provider appeals for denied days utilizing criteria sets Intraqual and Milliman and Robertson (M&R) in conjunction with clinical documentation and acute care needs. The overall objective is to reduce uncompensated care for UMMS, Kernan and Specialty hospitals.
Principal Responsibilities and Tasks
The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.
1. Determine staffing requirements and supervise and mentors the work of all direct reports to ensure effective and efficient departmental functions.
2. Hire, orient, train, conduct performance evaluations, handles corrective actions, and provide an open and goal oriented work environment with establish clear and concise work procedures and productivity standards. Conducts meetings on a periodic basis to maintain efficient and effective operation of department personnel.
3. Develops staff by providing opportunities and training programs to enhance individual employee’s career development
4. Monitors clinical denial departmental performance to ensure accurate and timely procedures on patient accounts. Develops, plans goals and presents objectives for the department with Director and Management Team.
5. Prepares performance reports on all clinical denials and distributes to monitor and evaluate the effectiveness of the department.
6. Participates in meetings and committees related to functions, and represents the department as necessary.
7. Reviews denials issued by KEPRO and MIDAS agents for appeal feasibility.
8. Supports the Senior Director of Patient Financial and Access Services in providing and interpreting reports of denied days statistics and trends identified from denials received to Patient Access Services, Case Management, Finance, Chief Medical Officer, and other hospital departments as requested.
9. Assists Patient Financial Services to determine the nature of the denial for cases rejected for payment by payors; assesses feasibility of appeal applying Interqual criteria and M&R criteria for length of stay.
10. Oversees the collection of data on denials and the retrieval of reports on denied days received by the facility, identifies trends, track appeal success, and provides and interprets reports of denied days statistics from denials received to Case Management, Finance, and other hospital departments as requested.
11. Oversees the compilation of denied days data, trends, and production of reports to aid in continued improvements in authorization procedures, decreasing the length of stay, and ensuring more cost effective delivery of patient care services.
As an employee of the University of Maryland Medical System (UMMS), you will enjoy a comprehensive benefits program designed with you and your dependents in mind. Subject to any eligibility waiting period, all of the benefits are available to regular full-time employees and most benefits are available to regular part-time employees who are regularly scheduled to work twenty (20) or more hours per week. Many benefits are provided at no cost to employees. For others, the cost is shared between UMMS and employees
1. Graduate of an accredited School of Nursing with current R.N. licensure required.
2. Bachelor of Science in Nursing preferred.
3. Five years professional nursing experience, with experience in a patient care setting and two years performing Utilization Review/Quality Assurance/Case Management responsibilities.
Knowledge, Skills and Abilities
1. Demonstrates expertise in management operations including but not limited to managing, supervising, directing, and monitoring the daily work activities of subordinate personnel.
2. Demonstrates ability to perform responsibilities in a fast paced, work environment, requiring excellent organizational skills, sound judgement, and critical decision making.
3. Proficiency in understanding the application of hospital protocols, both standardized, the Joint Commission stipulated and those specific to UMMS, in order to read, interpret and follow medical procedures in patient chart.
4. Demonstrated technical expertise with computer hardware, software and database management functions and duties. Proficiency with Excel, Access, and PowerPoint.
5. Excellent written and verbal communication skills are necessary to successfully perform all managerial responsibilities.
6. Demonstrates ability to ensure office environment and facilities are maintained in an orderly fashion and conducive to efficient operations. Develops and maintains contacts.