Job Summary:

Manages the appeal process for governmental claims, including but not limited to obtaining pertinent clinical documentation of accounts and writing appeal letters. Additional responsibilities includes monitoring referrals and admissions from high risk accounts and other duties as applicable. When denials are received from CBO, the Criteria Manager prepares and submits appeals in a timely manner to ensure accurate and timely responses.

Serves as a liaison between CBO and the marketing teams. Coordinates appeals on government claims, converting where appropriate from LTAC qualified to site neutral payment. With cooperation from the Clincial Liasion, reviews pre-admission and current clinical documentation as needed to compile appeals.. Identifies opportunities for process improvement and facilitates necessary changes and trainings to the Business Development Team and CBO. Identifies and implements training for adherence of submitting criteria documentation. For high risk accounts, the Criteria Manager will review clinical documentation upon receiving referrals to ensure proper revenue codes and/or documentation are obtained prior to accepting patients for admission.

Essential Functions:

• Identifies trends with claims and manages the training of field and business office employees to adhere with submission requirements
• Identifies CLs not submitting correct documentation for compliant claims and provides on-going training to remediate non-compliance.
• Provide education to management relating to payer trends and patterns so Centralized
• Business Office and Managed Care can address to assist with more timely liquidation of claim.
• Ability to review medical, financial and admission criteria documentation to prepare technical appeals or documentation required to timely adjudicate the claim.
• Excellent writing and organizational skills.
• Identifies and submits examples of egreious managed Medicare denials to CMs site as instructed by Regional Director of Admissions.
• Knowledge of accreditation standards and compliance requirements to act as resource for regional management and Central Business office
• Utilizes Knowledge of government and non-government payer practices, regulations, standards and reimbursement processes to develop best practices and implement continued training opportunities with Business Development team and Central Business Office
• Continually monitor changes in criteria guidelines and industry best practices with regular review of periodicals, web sites ,other media and appropriate continuing education.

Knowledge/Skills/Abilities/Expectations:

• Working knowledge of healthcare law.
• Strong leadership skills
• Strong written and verbal communication skills.
• Ability to work with individuals at all levels of the organization.
• Knowledge of long-term acute care industry.
• Knowledge of state and federal regulations.
• Proficient computer skills, including current Microsoft Office programs, especially word-processing and spreadsheet software
• Ability to analyze, research, and interpret.
• Approximate percent of time required to travel: 0%
• Must read, write and speak fluent English.
• Must have good and regular attendance.
• Performs other related duties as assigned.

Education:

• Bachelor's degree in healthcare field required

Licenses/Certification:

• Registered Nurse preferred but not required

Experience:

• 3+ years experience in clinical setting preferred
• 3+ years experience in healthcare management