Manager, Clinical-Coding Payment Resolution Specialist

POSITION PURPOSE

Manages and oversees the payment resolution team responsible for all clinical and coding based denials at a PBS location in order to  ensure payments are received on denied accounts, determine root causes of denials, and prevent future denials by identifying trends and providing feedback to appropriate local RHM departments. Motivates staff to achieve the highest levels to meet the organization goals for customer service, operational and financial performance.  Attends managerial meetings and supports the core values of Trinity Health, which is an integral part of this position This position reports directly to the Director  Payment Resolution.

Provides financial education management, leadership and expertise in overseeing all details of assigned operations for clinical and coding based denials, and works in conjunction with other departments, including but not limited to payer strategies, patient access, Trinity Health Information services (TIS), general accounting, clinical departments, medical groups and other service areas to ensure that the financial and customer service goals are optimally accomplished.  Responsible for systematic approaches that contribute to the capture, management and collection of patient service revenue for all clinical and coding based denied accounts, as well as maximizing the organization’s net patient revenues, while maintaining strong regulatory and legal compliance, and high levels of customer service.

ESSENTIAL FUNCTIONS

Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.

Manages and oversees the day-to-day responsibilities of the clinical and coding denials team handling the receipt, analysis, and appeals of denials received in order to achieve optimal area performance and colleague productivity goals as part of the revenue cycle process for an assigned PBS location.

Responsible for understanding complexities involved in supporting clinical and/or coding denials operational activities spanning multiple states, regional health ministries, payer environments, and technologies to manage team of colleague specialists accordingly.

Monitors final adjustments on completed clinical and coding denial accounts (either paid or final denied), and reviews documentation in appropriate system(s).

Reviews and tracks trends for the causes for clinical and coding denials and makes recommendations for problem and issue resolutions based upon colleague specialist findings; reports findings to the Manager and Director of Payment Resolution and other PBS leadership along with local RHMs.

Assists the Director Payment Resolution in the development of broader goals and objectives based on PBS needs and to ensure continuous improvement in quality, operational cost effectiveness, customer satisfaction and resource utilization.

Provides Director Payment Resolution with regular updates of results, barriers to performance and opportunities for continued improvement.

Manages communication and follow-up processes related to clinical and coding denials and ensures such activities are submitted, tracked, trended and reported timely to key stakeholders.

Prepares service level metrics and explanatory summaries for the Director Payment Resolution and other PBS leadership.

Participates with peers and the Director Payment Resolution in the redesign of clinical and/or coding denial management processes and systems to improve service, data integrity, and staff productivity/quality to achieve departmental goals and process outcomes.

Identifies and participates in continuous quality improvement initiatives across the clinical and coding denials team and other functional areas to streamline processes.

Identifies and implements solutions to problems and issues affecting clinical and/or coding denials activities.

Manages assigned staff to ensure steady workflow balance and high-quality outcomes anticipating and planning for staffing fluctuations:

  • Interviews, selects and is accountable for the on-going development and evaluation of colleagues within the area of responsibility;
  • Develops colleague work schedules to ensure cost effective staffing that meets customer requirements and financial performance;
  • Establishes, implements and evaluates on-going performance improvement programs, utilizing an interdisciplinary approach; 
  • Responsible for the financial and personnel management of assigned areas, and
  • Effectively directs and facilitates a multidisciplinary team to achieve its desired outcomes.

Creates and monitors a culture supportive of personnel by fostering individual motivation, teamwork and high levels of performance and accountability utilizing a participative management style to ensure staff retention. Identifies action plans to improve the quality of services in a cost-efficient manner and facilitates plan implementation.

Maintains professional development and growth through journals, professional local, regional and national affiliations, continuing programs, seminars, and workshops to keep abreast of trends in revenue cycle operations and healthcare in general:

  • Develops and implements an annual plan of personal and professional development.

Serves in a leadership role and promotes positive Human Resource Management skills by fostering teamwork between business and clinical stakeholders and by recruiting, retaining, training, mentoring, developing and managing staff to achieve strategic objectives.

  Identifies training needs and coordinates with the System Office Training team to develop and conduct training programs, which includes on-the-job training.

Assists with establishing performance standards for clinical and coding denial colleagues. Monitors and tracks colleague activities against established performance standards and provides immediate feedback to achieve performance improvement.

Other duties as needed and assigned by the Director.

Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health’s Integrity and Compliance Program and Code of Conduct, as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior.

MINIMUM QUALIFICATIONS

Must possess a comprehensive knowledge of revenue cycle operations, including Patient Access, HIM, Patient Accounting and Revenue Management, as normally obtained through a Bachelor's degree in Healthcare or Business Administration, Education, Finance or Accounting, or a related field and a minimum five (5) or more years of experience in the Denials Management or an equivalent combination of education and experience. Experience in a complex, multi-entity healthcare organization or large complex revenue cycle services preferred.   

Registered Nurse and a graduate of an accredited school of nursing, or Licensed Practical Nurse (LPN) is preferred, plus at least four years of nursing experience preferred.

Possesses a strong working knowledge of clinical fundamentals and medical terminology as well as experience with clinical based denials and payment resolution, to include two (2) years of utilization review/case management, managed care or comparable patient payment processing experience.

Ability to interact effectively with multidisciplinary teams, including physicians and other clinical professionals internally and externally.

Must possess comprehensive knowledge of hospital and professional/physician diagnostic and procedural coding, as normally obtained through a coding certificate program and least five (5) year of physician/professional or hospital outpatient coding experience or minimum of five (3) years of relevant hospital inpatient coding experience including DRG assignment.

Must be a Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or coding credential of a Certified Coding Specialist (CCS) or Certified Professional Coder (CPC).

Must have experience with National Correct Coding Initiative edits (NCCI), National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and Outpatient coding guidelines for official coding and reporting.

Exhibits superior management skills that emphasize team‑building and strong leadership with the ability to provide clear direction to the department.

Supervisory experience.

 Must have an understanding of denials resolution based on patient status, length of stay, level of care, missing pre-certification, or other clinical reasons.

Possesses knowledge of and experience in case management and utilization management.

Certification within Healthcare Financial Management Association (HFMA) is desirable.  Possesses a comprehensive understanding of project management, quality assurance, regulatory requirements and service documentation, clinical and charging process, denial management, process improvement, training, revenue cycle technology infrastructure and related issues. 

Ability to lead and manage multiple, concurrent running projects, prioritize tasks and adapt to frequent changes in priorities.  Ability to recognize necessary changes in priority of tasks and allocation of resources, and bring them to the attention of PBS -leadership,  

Exhibits strong management with the ability to attract, develop, deploy and retain a world-class revenue cycle team, capable of performing as a team and of evolving with the organization’s vision and with cutting-edge technologies.

Ability to address complex problems with multi-level impacts and with solutions not readily apparent.  Uses sound judgment, in depth analysis and expertise to resolve issues.

Ability to prioritize and deliver on key initiatives; demonstrated success in achievement of key performance metrics targets within time and budget constraints.

Strong written and verbal communication skills. Ability to communicate effectively with payors and work with all levels of colleagues to expedite revenue cycle processes while supporting customer service.

Effective critical thinking and problem-solving skills. Ability to analyze data and prepare related reports and summaries.

Proficiency in Microsoft Office, including Outlook, Word, PowerPoint, and Excel.

Strong organizational skills supervising direct reporting relationships.

Must be comfortable operating in a collaborative, shared leadership environment.

Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.

PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS

This position operates in a typical office environment. The area is well lit, temperature controlled and free from hazards.

Incumbent communicates frequently, in person and over the phone, with people in all locations on product support issues.

Manual dexterity is needed to operate a keyboard. Hearing is needed for extensive telephone and in person communication.

The environment in which the incumbent will work requires the ability to concentrate, meet deadlines, work on several projects at the same time and adapt to interruptions

Must be able to set and organize own work priorities and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles.

Must possess the ability to comply with Trinity Health policies and procedures.