Government Appeals Manager - Compliance Billing Integrity
The Government Appeals Manager serves as the centralized source for planning, supporting, coordinating and overseeing the government claims appeal processes for Stanford Health Care and Stanford Children's Health. The Government Appeals Manager ensures effective defense, management and submission of government payor appeals related to inpatient and outpatient claims, including Medicare and Medicaid Recovery Audit Contractor appeals.
The position is responsible for reviewing medical records for development of defense strategy, including medical necessity of inpatient stays, and compiling relevant medical record documentation and other information in support of appeal defense. Responsibilities include tracking appeals through all levels of the appeal continuum; creating, coordinating and maintaining case files; ; ensuring timely submission of appeals; calculating repayment projections; analyzing and trending appeal data; creating and submitting appeal letters; and creating and maintaining spreadsheets, benchmarks and presentation materials related to appeals data.
The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned. Specific duties and responsibilities may vary depending on department or program needs without changing the general nature and scope of the job or level of responsibility entailed.
Employees must abide by all Joint Commission requirements including, but not limited to, sensitivity to cultural diversity, patient care, patients' rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.
Employees must perform all duties and responsibilities in accordance with the C-I-CARE Standards of the Hospital. C-I-CARE is the foundation of Stanford's patient-experience and represents a framework for patient-centered interactions.
Reviews medical records for development of defense strategy, including medical necessity of inpatient stays, and compiles relevant medical record documentation and other information in support of appeal defense;
Drafts and compiles case defense strategy and relevant documentation, communicates with physicians regarding participation in defense strategies;
Reviews medical record documentation to identify, analyze, produce and timely submit all medical record documentation relevant to appeals;
Compiles and maintains case documentation files, including relevant medical and billing records, correspondence, defense strategies, and other documentation.
Analyzes, tracks and trends all appeal findings through all levels of appeal;
Oversees and ensures accuracy of government appeals databases, analyzes data and produces reports, spreadsheets and presentations regarding trending of data and predictive modeling of future appeals;
Conducts analysis and trending of data for identification of potential billing integrity risk areas, billing integrity improvement opportunities and risk reduction actions;
Analyzes appeal data for calculation of repayment projections, cost benefit of appeals and decision support;
Receives, logs, tracks, analyzes and timely responds to all government appeals correspondence;
Conducts research to ensure institutional knowledge and application of current information related to regulatory developments in government appeals, industry appeal strategies, data and trends;
Maintains knowledge and credentials sufficient to conduct medical record review and analysis.
All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, protected veteran status or on the basis of disability.Minimum Qualifications
Any combination of education and experience that would likely provide the required knowledge, skills and abilities is qualifying.
Education: Bachelor's degree in a work-related discipline/field from an accredited college or university; Registered Nurse or Physician preferred.
Experience: Minimum of three (3) years of progressively responsible and directly related work experience.
Licenses/Certifications: Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), or Certified Coding Specialist (CCS) or RN with direct government claims defense experience. Registered Nurse or Physician with claims defense experience preferred.
Knowledge, Skills, and Abilities:
Demonstrated ability to apply judgment and make informed decisions;
Demonstrated ability to plan, organize, prioritize work independently and meet deadlines;
Demonstrated ability to analyze and develop solutions to complex problems;
Demonstrated ability to apply critical thinking to identify patterns and trends;
Demonstrated ability to speak and write effectively at a level appropriate for the job including summarizing data and presenting results;
Demonstrated skills in performing regulatory and industry research relevant to functional responsibility;
Knowledge of medical records, medical terminology, Medicare guidelines, principles of ICD-9/ICD-10 and CPT coding;
Demonstrated skills navigating in an electronic medical record environment;
Demonstrated skills in Microsoft Office, databases and spreadsheets.