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Clinical Appeals Program Manager (Zion IL)

Cancer Treatment Centers of America Type Full time Posted 1/18/2014
Salary - n/a - Starts 4/16/2014
IL - Illinois (All) - Zion Referral - n/a -    

Clinical Appeals Program Manager (Zion IL)

Location:Cancer Treatment Centers of America Operations Center
Region:Zion, IL
Department:428001 PA PARs-Mgmt
Employment Status:Full time
Shift Hours / Days:
Hours / Pay Period:80
Position ID:32884
Job Function:Professional


Clinical Appeals Program Manager

We Fight Cancer: Care That Never Quits®

Cancer Treatment Centers of America®(CTCA®) delivers an extraordinary patient experience we callPatient Empowered Care®. We deliver state-of-the-art, high quality care through an integrative model where a team of experts puts patients at the center of their own care. Every day, you will help patients win the fight against cancer. Every day is challenging and rewarding beyond your imagination.

A Culture of Teamwork, Empowerment & Development

CTCA provides Stakeholders with exceptional support and easy access to a wide range of tools and resources they need to bring the best of themselves, every day. Our benefits, wellness, and compensation programs lead the market. Imagine access to your own personal health coach! We also provide extensive training and career development opportunities that encourage professional and personal growth—it is a point of pride. We empower our Stakeholders to deliver the highest standard of care, which we call the Mother Standard®.

The Clinical Appeals Program Manager (CAPM) is responsible for facilitating complete, timely, and accurate follow up on clinical denials, as well as, facilitating appropriate clinical appeals for both hospital and physician claims be submitted to insurance payers, third party reviewers, networks, and employers.  CAPM will provide assistance to Compliance who will coordinate any government payer denial responses.  This includes providing ongoing consulting to the site resources to optimize overall reimbursement and insure our patients receive the best CTCA has to offer in denials and appeals management.  The CAPM will evaluate clinical denials and appeals to make a determination as to the appropriate course of action and to automate and streamline the work process whenever possible.  The CAPM will draft clinical appeals as clinically appropriate within area of expertise and act as the CTCA liaison with the clinical and physician resources at the sites to bring appeals to resolution.  This includes CAPM providing the necessary consulting, guidance, and clarification to the identified clinical functional resource at the sites.  The CAPM will initiate communications with insurance payers, third party reviewers, networks, employers and government payers and will be a point of contact for clinical appeals.  The CAPM will reassign the claims to the appropriate site resource via the denials management technology when appropriate and provide ongoing consulting and support to bring the denial to resolution.  This will include frequent and regular interactions with clinical professionals including physicians to fully understand claims, patient services included in claims, and troubleshoot items impacting the processing of claims.  The CAPM will be responsible for identifying denials and appeals trends and developing recommendations for mitigating future denials.  The CAPM will also have responsibility for developing and maintaining an appeals library which includes standardized appeals letter templates for use in processing appeals and creating a library of appeals templates which address scenarios that are repetitive.  This role will support the business process development for the Denials and Appeals Management function and provide consulting relating to the clinical processes impacting this function.  This also includes developing and conducting business process and technology training.  The CAPM will be the liaison to the site resources who are key delegates in the denials and appeals management process.  The CAPM will collaborate with Compliance resources to isolate denials trends and identify education opportunities and mitigation strategies to prevent future denials.  The CAPM will also be responsible for presenting trends and mitigation opportunities to leadership and clinical professionals (including physicians).  The CAPM will partner with Compliance to assist with any on-site denials mitigation training needs Compliance is responsible for.  The CAPM will make write off recommendations to the AMS Supervisors for denials or appeals that are deemed uncollectable.

Education/Experience Level

  • RN certification with strong knowledge of the clinical process
  • BS in Nursing
  • 5+ years of experience with working knowledge of clinical processes and EHR systems.
  • 5+ years experience in utilization management, case management, process improvement and/or information systems
  • Knowledge of clinical coding and reimbursement and/or claims management

Knowledge and Skills

  • Must have the ability to identify root causes and problem solve.
  • Seasoned clinical professional with demonstrated skills communicating with clinical professionals at all levels
  • Must have experience with business process development and change management.
  • Comfortable presenting outcomes and recommendations to all levels of the organization.
  • Demonstrates team facilitation skills.
  • Ability to formulate recommendations from trends and analysis.
  • Must possess sound analytical skills.
  • Aptitude with technology both as a user and with the ability to provide feedback regarding the effectiveness of applications.
  • Must have solid knowledge of medical terminology, most recent ICD coding methodology, CPT/HCPC's codes.
  • Fluent in EHR, electronic healthcare/medical records applications. Preferably AMPFM and SCM.
  • System report writing experience beneficial.
  • Must have excellent organizational skills, and be able to manage multiple priorities and responsibilities.
  • Must have outstanding verbal and written communication.
  • Must be willing to travel, as needed.

The Best Place to Work

We call ourselves Stakeholders because we all have a stake in the care and success of every patient. Today, CTCA Stakeholders deliver healing and hope to patients fighting complex and advanced cancer in Atlanta, GA, Chicago, IL, Philadelphia, PA, Phoenix, AZ and Tulsa, OK. Each of our hospitals, and corporate entities, earned aBest Place to Workdistinction and receives numerous accreditations that celebrate our culture of clinical quality, innovation, high performance and wellness.

Beyond The Resume, What We Look For

We select people with talent—people who value working with others and thrive in an environment of continuous improvement. We are creative and resourceful problem solvers. We are inventors and innovators. As a CTCA Stakeholder, you makethedifference in the life of a patient.

Do you see yourself working with a passionate team in a dynamic, high growth environment? Visitwww.cancercenter.com/careersto begin your journey.