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Guidehouse Clinical Denials Supervisor- Remote Location in MITCHELL, South Dakota

With a unique blend of large firm resources and an entrepreneurial collaborative culture, Guidehouse is where your purpose, passion, and expertise transform organizations. Guidehouse is a leading global provider of consulting services to the public and commercial markets with broad capabilities in management, technology, and risk consulting. We help clients address their toughest challenges with a focus on markets and clients facing transformational change, technology-driven innovation and significant regulatory pressure. Across a range of advisory, consulting, outsourcing, and technology/analytics services, we help clients create scalable, innovative solutions that prepare them for future growth and success. Headquartered in Washington DC, the company has more than 7,000 professionals in more than 50 locations. If you’re passionately motivated to make a difference and deliver exceptional work, we invite you to learn more about your career opportunities at www.guidehouse.com

Interested in working with talented people to help develop innovative solutions to some of society’s most complex and challenging problems? We are Guidehouse, a leading consulting firm serving the public sector and commercial clients with specialized capabilities in strategy, technology, and risk management. You may not yet know our name, but we have a rich history. Guidehouse is a combination of PwC’s former public sector practice and Navigant’s deep expertise in energy, financial services and healthcare.

We offer an exciting, fast-paced environment that fosters intellectual growth and rewards individuals based on impact, not tenure. Our firm is at the forefront of an emerging model solving complex problems that stretch across government and private companies, affording our people the opportunity to be on the cutting edge of the consulting profession. By focusing on markets facing transformational change, technology-driven innovation, and significant regulatory pressure, our employees also develop and deploy world class knowledge and problem solving that leads to breakthrough solutions.

Our healthcare segment is comprised of consultants, former provider administrators, clinicians, and other experts with decades of strategy, operational/clinical consulting, managed care services, digital health, revenue cycle management, and outsourcing experience. Professionals collaborate with hospitals and health systems, physician enterprises, payers, government, and life sciences entities, providing performance improvement and business process management solutions that help them meet quality and financial goals. You will make an immediate impact from day one, working with a team to provide end-to-end solutions. We don’t simply put band-aids on our client’s issues, we are working side-by-side with them. Are up for the challenge?

Business Process Management unites the strengths of four category-leading companies to address the complexities of today’s healthcare system. We design, develop and implement integrated, patient-centered solutions for sustained improvements in performance and profitability, working collaboratively across a spectrum of customers that encompasses hospitals, health systems, physician practice groups and payers.

The Clinical Denials Supervisor works closely with the Clinical Appeals Director and Manager and responsible for the evaluation and coordination of daily activities for clinical appeals team across all clients. The Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected, or emerging trends related to payer denials. This self-motivated individual has strong operational management oversight skills, is an expert on appeals/denials management and works extremely well with other departments to improve workflows and in a timely manner accomplish organizational goals and objectives.

  • Assists in clinical appeal implementation at all new clients.

  • Conducts comprehensive Denial Root-cause analysis and identifies trends involving non-clinical & clinical issues and reports on and recommends solutions.

  • Reviews data files from multiple sources, confirms accuracy and prepares executive level monthly reports on clinical appeals to present to client.

  • Educates others on appeals/denials guidelines on an ongoing basis.

  • Develops tracking and trending methodologies within Metrix for clinical appeal.

  • Create assessment and pre-assessment client tools for sales.

  • Actively participates in Revenue Cycle team meetings, communicates issues, and recommends process improvements.

  • Responsible for identification, research and coordinating a comprehensive response to problems, issues or concerns that have a cross functional impact throughout the Corporation and potentially impact the overall Corporate and divisional goals.

  • Conducts random quality audits and reports individual and team performance monthly.

  • Monitors team productivity, facility specific denials activity and targeted prevention strategies. Manages team's productivity and resources, communicates productivity expectations and balances workload to achieve customer satisfaction through prompt/accurate handling of customer concerns.

  • Demonstrates knowledge of process improvement techniques are essential to success, as is the ability to be a self-starter and work independently to move projects successfully forward.

  • Ability to work with a variety of individuals in executive, managerial and staff level positions.

  • Must be comfortable operating in a collaborative, shared leadership environment that encourages change engagement and participation, and open dialogue.

  • Demonstrating excellent customer service skills by facilitating communication between the hospital facilities and the payers.

  • Demonstrating effective assessment skills relative to providing adequate documentation and/or response as requested and/or required by the payers.

  • Analyzes and displays data in meaningful formats; develops and communicates policies/procedures and other business documentation; conducts special studies and prepares management reports, including key performance indicators as they relate to the division (waiting/service times, staff productivity, accuracy, patient satisfaction, customer feedback, incident reporting, etc.).

  • Maintains a good working relationship with physicians, case management, registration, billing office, and clinical areas and works to resolve issues.

  • Performs retrospective Medical Record reviews to assure complete and accurate physician/staff documentation is present for compliant coding reporting, lost charge audits, denial appeals &/or documentation integrity issues as per assignment detail-- including rationale for the initiation, discontinuation or adjustment of each treatment modality utilized in the care of the patient, lost charge identification &/or validity of Medical Necessity.

  • Utilizes clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied. Identifies risk factors, comorbidities and adverse events to determine if payer denial was justified and an appeal is required. Utilizes pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments. Prepares convincing appeal arguments, using pre-existing payer criteria sets and/or clinical evidence from existing library of clinical references.

  • Experience with Milliman ® or InterQual ® clinical criteria.

  • Researches regulatory policies to support clinical appeals.

  • Review record documentation for adherence to Medicare guidelines relating to inpatient services (or other Medicare issues) and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of services provided.

  • Provides direct communication with payors or facility staff as necessary for account denial resolution.

  • Work with guarantors to secure payment on account balances outstanding for clinical reasons.

  • Monitor insurance denials by running appropriate reports and contacting insurance companies to resolve claims denied for clinical reasons.

  • Completes data entry for tracking, trends, and analysis.

  • Stays current with HIM and Utilization Management trends, relevant rules, regulations, and directives from regulatory agencies and third-party payers.

  • Ability to communicate and work with patients, physicians, associates, Guidehouse, client leadership, multiple direct patient care providers and others to expedite the process. Strong communication skills (verbal and written) in dealing internal/external customers.

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

  • Maintain current knowledge of basic Coding Clinic Guidelines.

  • Regularly monitors the security and appropriate handling of all patient records to ensure HIPAA compliance.

  • Must be able to independently set and organize own work priorities for self and for the assigned team, and successfully adapt to new priorities as part of a changing environment. Must be able to multi-task and work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles.

  • Maintains current knowledge of processes and systems, regulatory and 3rd party payer issues and requirements.

  • Effective critical thinking, problem solving and decision-making skills. Strong quantitative and analytical abilities to process and display data.

  • Must possess the ability to comply with Guidehouse and client policies and procedures

  • Other duties as needed and assigned by the Manager.

  • RN and/or BSN Bachelor’s Degree in Nursing or an equivalent degree in an equivalent degree in a related discipline required, as well as a current state-issued RN license. Knowledge in areas such as InterQual Level of Care Criteria and Milliman & Robertson Criteria as well as knowledge of third payer regulations related to utilization and quality review. Interqual and/or MCG certification.

  • Significant experience in the healthcare field is required including a minimum of five years as a clinical nurse in an acute care setting. In addition, having at least two to three years’ experience in case management, discharge planning, and/or utilization review is preferred.

  • Computer experience in Microsoft Office (Word and Excel).

  • Knowledge of all regulatory and payer requirements for reimbursement and reason(s) for denials by auditors.

  • Ability to critically evaluate and make decisions about whether appeals should be made based on reviews of the patient medical record.

  • Writing skills and ability to convince appeals arguments that are sound and supported by evidence that is related to patients’ specific clinical attributes.

  • Ability to incorporate clinical references and/or regulatory arguments to support one’s own clinical appeals arguments.

  • Ability to prepare arguments for an Administrative Law Judge Hearing and participate in a hearing.

  • Maintain confidentiality of patient data and medical records in compliance with HIPAA regulations.

  • Excellent oral and technical writing and typing skills.

  • Demonstrated a willingness to learn and adapt to changes in regulations and task-related priorities.

  • Willingness to be flexible.

  • Excellent verbal and written skills.

  • Excellent organizational skills including effective time management, priority setting and process improvement.

  • Ability to successfully work independently and adapt quickly to changing priorities and regulations.

  • Ability to travel as required.

  • Other duties as assigned.

  • Strong conceptual, as well as quantitative and qualitative analytical skills

  • Work as a member of a team as well as be a self-motivator with ability to work independently

  • Constantly operates a computer and other office equipment to coordinate work

  • Regularly uses close visual acuity and operates computer equipment to prepare and analyze and transmit data

  • Generally works in an office environment

Additional Requirements

  • This position requires successful completion of a background check and employment verification.

  • The successful candidate must not be subject to employment restrictions from a former employer (such as a non-compete) that would prevent the candidate from performing the job responsibilities as described.

Guidehouse is an Equal Employment Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, citizenship status, military status, protected veteran status, religion, creed, physical or mental disability, medical condition, marital status, sex, sexual orientation, gender, gender identity or expression, age, genetic information, or any other basis protected by law, ordinance, or regulation.

Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.

If you have visited our website for information about employment opportunities, or to apply for a position, and you require an accommodation, please contact Guidehouse Recruiting at 1-571-633-1711 or via email at RecruitingAccommodation@guidehouse.com . All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation.

Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee.

Rewards and Benefits

Guidehouse offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.

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