Manager, Appeals (Full- Time) Remote- Hybrid

Job Overview:

Our Denial Management Recovery Services division is an integral part of our company's success. The Manager of the Appeals team within the RWJ Barnabas healthcare facilities is responsible for managing technical and clinical denials and works to resolve the denials and authorizations. He/she will collaborate with Case Management and Centralized Scheduling to ensure compliance pertaining to the denial/appeal process with a focus on obtaining optimal reimbursement.

This position will provide staff support to communicate with third-party payors to resolve discrepancies prior to billing. This position will also handle audit-related / compliance responsibilities and other administrative duties as required.

Qualifications:

• Bachelor s degree required in Finance, Healthcare or related field
• At least five years' managed care appeal experience
• Focused denials and appeals management experience required
• Must have excellent interpersonal, oral, and written communication skills
• Must have excellent organizational and time management skills.
• Strong project management skills and advanced problem-solving and analytical skills
• Knowledge in capturing, analyzing and communicating measurement results
• Strong Microsoft Office skills, particularly Microsoft Excel
• Ability to work well individually and in a team environment

Essential Functions:

• Demonstrates the ability to critically think, problem solve and make independent decisions supporting workflow and appeal process.
• Maintain and organize the workflow to ensure that denials are worked according to departmental policy and standards.
• Create action plans, process improvement and address gaps and opportunities for improvement from front end to back end
• Maintain training documents.
• Create a systematic reporting mechanism monthly that analyzes denials, identifies changes and/or trends, and reports these to management.
• Identify all denial trends and provide education of steps to prevent future avoidable denials.
• Research payer denials related to referral, pre-authorization and medical necessity.
• Validate denial reasons and ensure denial reasons are accurate and reflect the denial reasons codes.
• Generate an appeal based on the dispute reason and contract terms specific to the payer. This includes online reconsiderations.
• Follow specific payer guidelines for appeals submission.
• Escalate exhausted appeal efforts for resolution.
• Research contract terms/interpretation and compile necessary supporting documentation for appeals adjudication issues, and referral to refund unit on over payments and recoupments.
• Work payer projects as directed
• Develop and support effective working relationships among various departments for root cause analysis and resolutions
• Reviews accounts and makes recommendations to management regarding non collectible accounts.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Additional Information:

At RWJBarnabas Health, our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees physical, emotional, social, and financial health.

• Paid Time Off (PTO)
• Medical and Prescription Drug Insurance
• Dental and Vision Insurance
• Retirement Plans
• Short & Long Term Disability
• Life & Accidental Death Insurance
• Tuition Reimbursement
• Health Care/Dependent Care Flexible Spending Accounts
• Wellness Programs
• Voluntary Benefits (e.g., Pet Insurance)
• Discounts Through our Partners such as NJ Devils, NJ PAC, Verizon, and more!

Choosing RWJBarnabas Health!

RWJBarnabas Health is the premier health care destination providing patient-centered,

high-quality academic medicine in a compassionate and equitable manner, while delivering

a best-in-class work experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time. As the leading academic health system in New Jersey, we advance innovative strategies in high-quality patient care, education, and research to address both the clinical and social determinants of health.

RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state. We understand the growing and evolving needs of residents in New Jersey whether that be enhancing the coordination for treating complex health conditions or improving community health through local programs and education.