ABOUT HEALTHRISE

HealthRise is a dynamic healthcare consulting firm laser focused on revenue cycle management optimization and sustainable success. We hire and retain the industry’s top talent – we push boundaries and thrive on fierce conversations, which is why our track record is unmatched. HealthRise cultivates a culture of accountability; our team members aren’t satisfied with the status quo. We look for game changers who are driven by opportunity to grow personally and professionally, make money and feel empowered. A tech-enabled firm that stays ahead of the rapidly evolving healthcare industry, HealthRise deploys a Full Continuum approach that begins with an operational foundation, builds with our expert consulting and ends with relentless execution.

THE OPPORTUNITY

The Clinical Denials Improvement Director provides advisory-level support to ensure that patient care is facilitated, coordinated and integrated across the continuum in order to enhance patient and family engagement, and secure reimbursement. Additionally, this role assures that care coordination is outcomes-focused and is managed in a cost-effective manner to decrease length of stay, manage readmissions, obtain payer authorizations, and to effectively manage utilization review functions at the site.

KEY RESPONSIBILITIES

Provide consulting services to partners in one or more areas of the healthcare revenue cycle, which includes:

• Oversees the quality of care coordination services rendered, ensuring efficient management of assignments, competency and educational needs of the Care Management staff.
• Effectively coordinates and controls resources to established client outcomes and management objectives.
• Provides day-to-day oversight of Care Management and other revenue cycle operations, ensuring all practices and programs are aligned with the overall strategic plan of the organization and follow best-practice standards.
• Identification of key metrics and benchmarks based on facility size and payer mix; provide consulting support and lead process improvement initiatives to meet benchmarks.
• Analyze payer denial data and conduct gap analysis to prevent and appeal denials to improve revenue.
• Identify issues with payer contracts and partner with managed care department to provide feedback.
• Form partnerships with clinical leaders and physician advisors to identify trends in clinical documentation and makes recommendations to improve.
• Conduct detailed review of current state processes and gap analysis from best practice and implement process improvements.
• Ensures all care management policies and procedures are being consistently applied within the department.
• Provides training to staff and addresses any gaps in policies and procedure that are identified.
• Establishes guidelines for safe and appropriate care planning by matching patient needs with appropriate services, delivering the most effective, accessible and efficient healthcare
• Sets direction for Care Management staff, ensuring accountability, quality outcomes, and follow-through.
• Evaluates patient care data to ensure that care is provided in accordance with clinical guidelines and organizational standards.
• Provides leadership and direction to direct reports.
• Provides input to strategic decisions that affect the functional area of responsibility.
• Completes corrective action plans on identified deficiencies and is responsible for creating, implementing, and monitoring changes and reporting outcomes.
• Works collaboratively with other areas of the revenue cycle to create a comprehensive patient care continuum supported by inter-departmental communications, documentation principles and management, and proactive participation in daily rounds, and stakeholder meetings.
• Performs all other related duties as assigned.

CANDIDATE PROFILE

A Director must have vast experience in project and/or program management. He/she must possess outstanding communication, listening and interpersonal skills and be comfortable directing or challenging clients and coworkers. The successful candidate will be able to establish credibility and rapport quickly with a broad set of partner and internal team members. He/she will understand Care Management and will be able to drive strategic planning and change management activities in this area.

The ideal Director candidate represents and demonstrates our CORE VALUES:

• ALL IN– We all work collectively toward the same goal: brightening our company’s future.
• HEALTHY RELATIONSHIPS– We are trustworthy and accountable, establishing strong, lasting bonds with our partners and each other.
• CONTINUOUS IMPROVEMENT– We aim to improve every day, both personally and professionally.
• COMPETITIVE– We push and encourage each other to be the best, knowing our team becomes stronger when we strive for greatness together.
• EXCELLENCE– We aspire to get it right every time, delivering professional, high quality results.

POSITION REQUIREMENTS

• Bachelor/Master’s degree in Nursing not required, however high proficiency in working and communicating with clinical stakeholders is required
• Direct experience in supporting and/or managing CM/UM (Care Management and Utilization Management) workflows, operating as department leader, consultant, or change agent
• Direct experience in driving denials management improvement, including identification of root cause issues in clinical denials workflow and implementing process improvement steps
• Certification in Case Management preferred
• Epic expertise within the continuum of revenue cycle
• Solid understanding of revenue cycle workflow in the hospital environment (registration, scheduling, utilization review, coding, billing, contracting)
• A high degree of self-motivation, versatility and flexibility
• Ability to work closely with groups outside of your organization/control (i.e. consultants or clients)
• Excellent presentation skills
• Strong attention to detail and follow-through skills
• Critical thinking and problem-solving skills