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What will you be doing in this role?

Under the direction of Compliance and Revenue Integrity, the Clinical Program Coordinator is responsible for overall management and communication of clinically based appeals between CS and outside payers. The Clinical Program Coordinator will also act as a liaison and point of contact to/for Case Management and other CSMC representatives for denial and appeal inquiries. In addition, the Clinical Program Coordinator will actively manage, maintain and communicate to appropriate partners denial and appeal activities, trends, and recommended corrective action plans. Duties include:

• Identification and facilitation of educational opportunities with case management department, providers, and payers to decrease denials and improve quality of service to patients.
• Provide periodic educational sessions to case management department in relation to denial trends, changes in reimbursement mechanisms that can affect patient access to service, and updates in contractual agreements that may affect case management process.
• Reviews all denials and determines appropriates of appeals by audit type and timeline.??
• If appeal is appropriate, constructs letter of appeal documenting a clinically oriented rebuttal to denied days/services based on professional judgment, provided documentation and/or community standards.
• Incorporates into appeal letter contractual and/or regulatory support for days/services denied as appropriate.
• Maintains strict adherence to all timelines in order to meet deadlines for submission of appeal and avoid loss of appeal due to lack of timeliness.
• Uses electronic data base to track reason for denial, result of denial review as it relates to ability to appeal, date of appeal actions, outcome of appeal if appropriate.
• Monitors for response to appeal as appropriate.
• Provides for follow-up communication and feedback when response is not received in a timely manner.
• Coordinates communication for second level appeals when appropriate
• Makes recommendations for advance of appeal efforts to legal level.
• On cases where no appeal is appropriate provides documentation to support decision
• Monitors, identifies and reports on suspected or actual trends in denials.
• Works in collaboration with Case Management, providers, other CSMC departments and health plans to develop corrective action plans to address identified trends in reasons for denials.
• Monitors and reports on revenue recovery resulting from appeal efforts.
• Maintain knowledge of federal, state and other regulatory agency rules and regulation including The Joint Commission, CMS, Medi-Cal, etc.
• Maintain current knowledge of Medicare, Medi-Cal and other third-party payor reimbursement requirements.
• Maintain awareness of evidenced based clinical practices.
• Completes retrospective review on patients whose admit and discharge time frames did not allow for concurrent UR as cases are identified.
• Assists as needed with government audits, including but not limited to R.A.C, CERT, PROBE, by participating in review of identified cases and writing of response letters.??

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Requirements:

• Associate's degree or college diploma required. Bachelor's degree in healthcare, management, business administration or a related major preferred.
• RN required.
• Minimum of Commercial/government denials and appeals experience preferred.

Why work here?

Beyond outstanding benefits, competitive salaries and health and dental insurance We take pride in hiring the best employees. Our talented staff reflects the culturally and ethnically diverse community we serve. They are proof of our commitment to creating a dynamic, inclusive environment that fuels innovation and the gold standard of patient care we strive for.