As Appeals Management Supervisor you will oversee and coordinate the appeals process, act as a liaison to third party reviewers and coordinate and manage utilization issues concurrently and retrospectively as they relate to potential denials related to IPRO, managed care and third party reviewers. You will also assist with planning and implementation of patient care across the continuum.
- Acts as a liaison for IPRO, managed care and third party review organizations.
- Reviews, investigates, and responds to Managed Care and Third Party quality and utilization inquiries.
- Acts as a resource for all Hospital/System staff; communicates requirements to all appropriate parties within the Hospital and Health System.
- Develops and presents educational programs for all personnel affected by IPRO, Managed Care and Third Party Review.
- Oversees and coordinates appeals process.
- Sorts, reviews and evaluates cases denied by all Third Party payers and determines follow through for first, second and third level appeals within contractual or appropriate timeframes.
- Maintains data tracking systems and provides reports to Patient Accounts, Director of Case Management, Medical Director and Quality Management staff.
- Monitors inpatient denials and assists patients and physicians with management of the appeals process.
- Coordinates and manages utilization issues concurrently and retrospectively as they relate to potential denials related to IPRO, Managed Care and Third Party Reviewers.
- Demonstrates job knowledge and technical capability, serving as a resource to all hospital and System staff on IPRO, managed care and third party reviewers.
- Promotes staff development and education.
- Provides opportunities for formal and informal education to promote staff competency.
- Sets standards for performance and provides ongoing feedback to staff.
- Provides support and direction while holding staff responsible for results.
- Participates in departmental continuous quality improvement activities and committees.
- Bachelors Degree in Nursing, required. Masters Degree, preferred.
- Current license to practice as a Registered Professional Nurse in New York State.
- Minimum of five (5) years clinical experience, plus a minimum of two (2) years experience in case management/utilization management/discharge planning and third party payment systems.
- Maintains current knowledge of all IPRO, Managed Care and Third Party Review requirements.
- In-depth knowledge of the appeals and denial processes; strong communications skills and computer literacy.
Transforming care, optimizing patient satisfaction and creating better patient outcomes are just some of the things our talented team members are doing at North Shore-LIJ each and every day. As a culture committed to providing our customers with the highest quality service, we stand behind our core values: Patients first; Caring; Excellence; Innovation; Integrity and Teamwork. It is our commitment and our culture that sets us apart from others and is the cornerstone of everything we do. Join an organization whose team members are valued, cared for and offered continuous opportunities to grow. Click on the link to learn more about us: www.northshorelij.com/goals
Please note: North Shore-LIJ is a smoke-free environment. Smoking and the use of tobacco products is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises. Free smoking cessation programs and quit medications are offered to team members who wish to quit through the North Shore-LIJ Center for Tobacco Control.