Clinical Appeals and Medical Necessity Manager

City/State:

Yonkers, New York

Grant Funded:

No

Department:

REV - Utilization Management

Work Shift:

Day

Work Days:

MON-FRI

Scheduled Hours:

8:30 AM-5 PM

Scheduled Daily Hours:

7.5 HOURS

Pay Range:

$80,000.00-$100,000.00

Job Summary

This position directly manages the appeals process at the Wakefield Division of Montefiore Medical Center. This RN/PA/FMG/MD/HIM Professional responds to third party clinical denials, interfaces with health plans, works closely with Finance and Contracting regarding utilization management health plan issues, and advises the Director of denial trends. S/he analyzes Wakefield Division denials and acts accordingly to minimize the financial impact of third party payer denials. S/he ensures the Wakefield Division denials and appeals are documented properly in the designated automated tracking application. S/he performs first level review for FFS Medicare elective and emergent hospital admissions. S/he also acts as a resource regarding medical necessity to other associates of the department and to departments that interface with Utilization Management. S/he exhibits expertise in the knowledge of rules, mandates and regulations related to denials and appeals and educates and mentors Case Managers/CTCC's and related staff to ensure compliance with these. S/he will interface with the Case Managers/CTCC's in order to clarify clinical scenarios when medical record documentation is insufficient to do so and the Case Manager/CTCC's was involved with a case on a concurrent basis. CTCC's performing appeals activity report to this associate.

Qualifications:

• Bachelors degree in health care or related field required - Masters preferred
• RN/Physician Assistant/Foreign Medical Graduate/HIM Professional preferred
• Analytical skills required
• Knowledge of Medical Terminology required
• Experience in Managed Care/Utilization Management Required
• Excellent verbal and written communication and interpersonal skills required
• Excellent organizational skills required

Montefiore Medical Center is an equal employment opportunity employer. Montefiore Medical Center will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law.