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Network Director Clinical Appeals Job in Scottsdale, Arizona

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Job Title: Network Director Clinical Appeals

Skills:BSN and 2 years in a leadership role for hospital clinical denials,utilization review,clinical documentation,or quality management or 4 years clinical denials,utilization review,clinical documentation,or quality experience.
Specialties:hospital system
Required Certifications:Registered Nurse (RN) State And/Or Compact State Licensure
Required Experience:1 to 2 years
Preferred Experience:3 to 4 years
Location:8125 N Hayden Rd Scottsdale 85258, AZ, US
Date Posted:11/14/2019

HonorHealth is a non-profit, local healthcare organization known for community service and outstanding medical quality. HonorHealth encompasses five acute care hospitals with approximately 11,500 employees and 4,500 volunteers, over 70 primary and specialty care practices, clinical research, medical education, an inpatient rehabilitation hospital, an Accountable Care Organization, two foundations, and extensive community services.

HonorHealth is a leader in medical innovation, talent and technology with a genuine commitment to your growth. The health system's vibrant careers take place in an environment filled with opportunity and respect because we see the HONOR in you.


·         Bachelor's degree Nursing

·         2 years in a leadership role for hospital clinical denials, utilization review, clinical documentation, or quality management or 4 years clinical denials, utilization review, clinical documentation, or quality experience.

·         Registered Nurse (RN) State and/or Compact State Licensure Current RN licensure


This position plans, manages and coordinates clinical denial, charge capture, pre-service review, and medical necessity practices to ensure consistency, meets corporate compliance guidelines, and to ensure appropriate and effective reimbursement in cooperation with the following key areas: Utilization Management, Clinical Documentation, Health Information Management, Patient Financial Services, Admitting/Registration, Information Services, Laboratory and Radiology and Outpatient Surgery Departments, and Innovative Care Partners and hospital-based contracted physicians within the HonorHealth network. Provides education to physicians, and physician offices as needed to support hospital operations ensuring accurate and complete medical record. The Director is responsible for daily supervision of the clinical denial RNs, charge capture RNs, and pre-service review staff within the network and collaborates closely with other clinical leaders and senior leaders by communicating denial trends and opportunities for improvement. Assists the Senior Director of Revenue Integrity with the network clinical denial, charge capture, and pre-service review strategies and initiatives. Manages millions of dollars in denied claims and utilizes data for decision making regarding strategies to prevent and overturn clinical denials. Meets budget requirements and participates in budget preparation.

Develops an environment that supports excellence by leading and directing efficient processes in the clinical denial, charge capture, pre-service review, and medical necessity including: clinical appeals to ensure a high overturn rate, charge capture activities, and pre-service reviews to ensure clinical policies have been met prior to service.

Provides clinical supervision to the clinical denial, charge capture, and pre-service review staff and ensures that they are clinically competent to perform roles. Facilitates education programs in conjunction with the physician advisor and works to resolve educational gaps. Facilitates educational opportunities.

Develops long and short term goals and metrics to support strategic network goals. Creates policy and procedure for the network, including cross-functional process to ensure a streamlined processes between departments such as Pre-services, Patient Financial Services, Utilization Review, and Clinical Documentation. Assures implementation, achievement, and evaluation of network initiatives to support strategic goals.

Fosters collaborative partnerships that involve all disciplines within clinical denials, charge capture, and pre-service reviews with medical staff and members of related system departments.

Provides direct oversight of clinical denial, charge capture, and pre-service review interventions within HonorHealth hospitals and serves as a liaison with payers and the contracting department; attends and facilitates joint operating committees with payers, as needed. Elevates payer issues to contracting for resolution.

Directs, manages, and evaluates personnel, assuring consistent monitoring of staff competence. Sets direction and provides oversight for recruitment and retention strategies. Selects and hires personnel based on departmental budget, staffing plans, and personnel needs.

It is the policy of HonorHealth to provide equal opportunity in employment. Selection and employment of applicants will be made on the basis of their qualifications without regard to race, color, religion, creed, national origin, age, disability, sexual orientation, marital status, veteran status or any other legally protected status.


Please forward resume and cover letter to Paul Diaz, Talent Acquisition Specialist, padiaz@honorhealth.com or apply directly online at: https://external-honorhealth.icims.com/jobs/22734/network-director-clinical-appeals/job?mode=view&mobile=false&width=1224&height=500&bga=true&needsRedirect=false&jan1offset=-360&jun1offset=-300

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