• Manager-Insurance Communications

    Job ID
    38658
    Department
    Managed Care
    Category
    Business Support
    Job Location
    US-TN-Memphis
  • Overview

    Under the direction of the Director of Managed Care, responsible for organizing and providing leadership, clinical and administrative expertise related to claim denials and appeals. Responsible for developing strong effective strategies to address claim denials. Works cooperatively with patient's families, departments throughout the hospital, as well as physicians and their office staff, to assure the creation and timely submission of a persuasive, technical, and accurate appeal document. Works effectively with all payor representatives. Demonstrates flexibility and creativity in the function. Represents the hospital in all appeal activities. Maintains data on all appeals and their outcomes. Creates files of resources on legislation, state or payor initiatives and supportive arguments to be utilized in refuting denials. Is knowledgeable on, and coordinates all appeals including, arbitration, mediation and/or administrative hearings. Demonstrates significant success in reversing third party payor denials as measured by pre-determined performance requirements. Creates, on a routine basis, all Managed Care Appeals Reports. Drafts policies and procedures for Appeals function within Managed Care Department. Manages Appeals Analyst. Responsible for completion of all Centers of Excellence surveys. Responsible for developing, monitoring and maintaining St. Jude's participation in payor value-based pricing initiatives including but not limited to TennCare's Episodes of Care P

    Responsibilities

    Key responsibilities in the role of Manager- Insurance Communications under the direction of the Director of Managed Care:

    • Responsible for organizing and providing leadership, clinical and administrative expertise related to claim denials and appeals
    • Responsible for developing strong effective strategies to address claim denials
    • Works cooperatively with patient's families, departments throughout the hospital, as well as physicians and their office staff, to assure the creation and timely submission of a persuasive, technical, and accurate appeal document
    • Works effectively with all payor representatives
    • Demonstrates flexibility and creativity in the function
    • Represents the hospital in all appeal activities
    • Maintains data on all appeals and their outcomes
    • Creates files of resources on legislation, state or payor initiatives and supportive arguments to be utilized in refuting denials
    • Is knowledgeable on, and coordinates all appeals including, arbitration, mediation and/or administrative hearings
    • Demonstrates significant success in reversing third party payor denials as measured by pre-determined performance requirements
    • Creates, on a routine basis, all Managed Care Appeals Reports
    • Drafts policies and procedures for Appeals function within Managed Care Department
    • Manages Appeals Analyst
    • Responsible for completion of all Centers of Excellence surveys
    • Responsible for developing, monitoring and maintaining St. Jude's participation in payor value-based pricing initiatives including but not limited to TennCare's Episodes of Care P

    Minimum Experience

    • Five years related experience, preferably in insurance or managed care

    Minimum Education

    • Master's degree preferably in a clinical or research field is optimal

    • Bachelor's degree in a health-related field, RRA or RN plus 4 years related experience may be substituted for Master's degree

    Required Credentials

    • None

    Other Credentials

    • RN, RRA or similar licensure required

      MACHINES, EQUIPMENT, AND AIDS USED IN THE JOB:
      Standard office equipment
      Personal Computer

    EEO Statement

    St. Jude is an Equal Opportunity Employer

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