Clinical Denial Operations Manager (RN)
Franklin , Tennessee
November 23, 2017
About HCA

HCA, a Fortune 100 company with more than 200,000 employees, is one of the nation's leading providers of healthcare services, operating over 170 locally managed hospitals and over 100 freestanding surgery centers in 20 states and the United Kingdom. With its founding in 1968, HCA created a new model for hospital care in the United States, using combined resources to strengthen hospitals, deliver patient-focused care and improve the practice of medicine. HCA is a learning healthcare system that uses more than 27 million annual patient encounters to advance science, improve patient care and save lives. HCA has been named one of the world's most ethical companies for eight years in a row. At HCA, we are driven by a single goal: the care and improvement of human life.

The Performance Improvement (PI) Manager Clinical Denial Operations collaborates with other members of the PI denials team, Case Management, Parallon, Regulatory Compliance and Strategic Pricing & Analytics (SPA) to assess and manage Denial Management strategies for HCA. The Manager will analyze denial clinical data and develop solutions for denial reduction and prevention. The positon will support HCA facilities in denials related to medical necessity, timely filing and missing/invalid authorizations, notifications or other issues clinical in nature. The Manager will provide education and support to the Division Denial Managers on regulations, systems, and tools used in the denials process as well as to implement processes to reduce denials across the organization.

The position requires solid leadership, trust building, team building, as well as change management to influence and lead other HCA resources and business partners in order to ensure success of all organizational initiatives. This individual must possess strategic vision, excellent communication skills, proven facilitation skills, proven motivational capabilities, have an executive presence, and a demonstrated track record of delivering results and attaining goals.

  • Provides support for the operational effectiveness of the denials programs developed to support the organization at the corporate, division and facility levels.
  • Analyzes Case Management and other clinical operations and collaboratively develops solutions to resolve and prevent denials
  • Analyzes enterprise-wide denials data an conducts root cause analysis for clinical issues
  • Collaborates with Case Management to provide education to Division Denial Managers on documentation standards and payer requirements
  • Researches payer Medical policy coverage issues and provides guidance to resolve or prevent denials
  • Researches clinical information and participates in case development for dispute resolution
  • Identifies payer denial trends and works directly with Case Management, Parallon, and Managed Care resources to develop resolution strategies
  • Works directly with PI & CM Analytics & Technology teams to ensure consistent processes and standards are supported in defined tools and reports
  • Develops a culture of high performance and continuous improvement that values learning and a commitment to quality.

• Bachelor's degree required

4-6 years' experience with some relevant work experience required
Minimum of 3 years' experience in healthcare revenue cycle and/or clinical operations
RN required
Hospital Case Management or relevant experience preferred
Superior interpersonal skills at the executive level and the ability to work within a highly matrix environment is a must.
Excellent communication skills, both written and verbal.
Travel required up to 35%

A little about us:
HCA is the nation’s leading private provider of healthcare services. Comprised of locally managed facilities which include 230,000 employees at over 160 hospitals, over 120 surgery centers and 100 urgent care facilities in 20 states and the United Kingdom

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