Manager Clinical Appeals

 
Position: Manager Clinical Appeals

Job ID: 162677

Location: US-TX-Houston

Department: REVENUE INTEGRITY

Talent Area: Professional - Non-Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a-5p

About Texas Children's Hospital

Texas Children’s Hospital   Since 1954, Texas Children’s has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children’s hospital in Texas, and among the top in the nation by U.S.News & World Report as well as recognition from Houston Business Journal as one of this city’s Best Places to Work for ten consecutive years.   Texas Children’s comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Center for pediatric research; Texas Children’s Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children’s Hospital West Campus, a community hospital in suburban West Houston; and Texas Children’s Hospital The Woodlands, the first hospital devoted to children’s care for communities north of Houston. We have also created the nation’s first HMO for children, established the largest pediatric primary care network in the country and a global health program that is channeling care to children and women all over the world. Texas Children’s Hospital is also academically affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation.   To join our community of 14,000 dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.  At Texas Children’s Hospital, diversity, equity, and inclusion are at the core of our values and mission for the women and children that we serve. We are committed to providing a diverse and inclusive work environment for all faculty, staff and learners throughout our organization. We believe that each member of our one amazing team provides enrichment that allows us to create a lasting legacy for future employees of this great organization.   Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

Summary:

We are searching for a Manager of Clinical Appeals-- someone who works well in a fast-paced setting. In this position, you will ensure timely and effective management of clinical appeals and external audits for hospital and professional billing accounts in line with regulatory requirements. This job will supervise the team that manages appeals and audits, oversee their productivity, manage policies and procedures, and review quality metrics. Additionally, the Manager of Clinical Appeals is responsible for identifying opportunities to reduce the risk of revenue loss and manage escalations. This involves collaborating with internal and external stakeholders, such as revenue cycle, clinicians, and payers.

 

Think you’ve got what it takes?



Responsibilities :

  • Manage employee performance, timekeeping, staffing needs, and educational activities. Facilitates orientation of staff to Revenue Cycle, provides feedback and evaluation of progress. Maintains adequate levels of qualified and competent staff in the department by collaborating with the Leadership Team in the recruitment and hiring of employees. Manages and prioritizes workload on daily basis. Monitors and audits appeal deadlines, performance reports, and performance expectations as outlined by leadership.
  • Analyze relevant appeals data and create data models related to outcomes & quality metrics. Evaluates individual systems for optimal data and reporting purposes on an ongoing basis. Assess trends for opportunities for improvement in revenue containment and denial prevention. Reviews productivity reports and reports findings during monthly KPI (key performance indicator) meetings. Develops action plans as necessary to ensure department compliance.
  • Manage account escalations & projects. Communicates with various TCH departments, as well as with insurance companies, external auditors, and other stakeholders concerning pertinent information, revisions, changes, and clarifications with respect to the revenue cycle. Identifies problems and implements solutions to ensure minimal delay in departmental functions. Serves as liaison regarding complaints and accessibility. Identifies areas of inefficiency and facilitates/coordinates resolutions by acting as a liaison between departments across the TCH.
  • Maintain and ensure adherence to regulatory requirements. Collaborates with leadership in the planning and implementation process to support adherence to regulatory guidelines, regulations, federal and legislative obligations, as well as contractual agreements. Responsible for implementing the necessary revisions for internal processes and procedures to meet and satisfy all guidelines as indicated by an outside auditor.


Qualifications:

  • Being fully vaccinated against COVID-19, including any booster dose(s) of the COVID-19 vaccine recommended by the Centers for Disease Control when eligible, is required for all employees at Texas Children’s unless approved for a medical or religious exemption
  • Bachelor's Degree in Nursing
  • Licenses/Certifications: RN - Lic-Registered Nurses by the Texas Board of Nursing or Nursing Licensure Compact
  • Required 5 years of clinical and/or managed care experience.
  • Preferred 1-year clinical appeals & denials experience pediatric experience and Formal leadership experience


Apply Now
Current Texas Children’s employees – Please click here to login.
Create Profile or Log In Search Careers