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
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
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.