Vice President of Clinical Appeals | PAM Health Corporate
Vice President of Clinical Appeals | PAM Health Corporate
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Job Description
Overview
The Vice President of Clinical Appeals provides strategic leadership and day-to-day oversight of the companys preadmission clinical appeals program across all IRF and LTACH facilities. This role is responsible for managing a centralized team that reviews appeals and overturns pre-admission payer denials (commercial Medicare Advantage and other payers) for clinically appropriate patients. The VP works cross-functionally with clinical operations case management admissions and compliance teams to ensure timely evidence-based appeal responses that maximize patient access to care and ensure reimbursement integrity.
Responsibilities
- Demonstrates proficiency in all skills required by the Vice President of Clinical Appeals with a focus on converting both commercial and MCA clinically appropriate patients from denied authorizing for admission.
- Directly trains and supervises the clinical appeals team to ensure compliance with all regulatory policies with a goal of overturning pre-admission denials.
- Acts as an active member of the appeals team performing comprehensive analytical reviews of clinical documentation to determine if an appeal is appropriate.
- Prepares convincing appeal arguments using pre-existing criteria sets and/or clinical evidence from existing clinical references and/or regulatory arguments and prepares the response to payer in an effort to overturn the denial in a professional and concise manner.
- Prepares feedback and summaries of appeal activities by hospital to be included in the Monthly Operations Reports and utilization Management Reports as well as monthly reporting to the corporate team.
- Collaborates with the team and ensures adequate coverage for all responsibilities of the department.
- Assesses problem situations and after thorough investigation plans and implements corrective action.
- Adheres to all policies and procedures.
- Identifies and solves problems in a timely manner. Gathers and analyzes information skillfully and develops alternative solutions.
- Demonstrates dependability including: following and giving instructions; responds to management direction; takes responsibility for own actions; keeps commitments; commits to long hours of work when necessary to reach goals; completes tasks on time or notifies appropriate person with an alternate plan.
- Demonstrates unquestionable integrity in every aspect of work and when dealing with others. Consistently models desired behaviors and values established by PAM Health.
- Continuously manages administrative functions to ensure quality and timeliness. Manages accurate and timely activity and performance reports.
- Ensures compliance with HIPAA regulations including confidentiality as required.
- Guide the clinical appeals process from intake to resolution with a focus on expedited appeals of preadmission denials.
- Personally participate in complex or high-risk appeals performing clinical documentation reviews and preparing persuasive evidence-based responses.
- Ensure all appeal letters are timely accurate and aligned with regulatory guidelines payer requirements and accepted clinical standards.
- Monitor and report on appeal volume denial trends overturn rates and root cause patterns.
- Use data insights to drive proactive interventions payer education and process improvements.
- Ensure compliance with all federal state and payer-specific regulations governing clinical appeals and patient admissions.
II. Leadership
- Lead and oversee the national Clinical Appeals department ensuring performance consistency and compliance across all facilities and payers.
- Develop and implement standardized processes workflows and training programs to support effective pre-admission appeals.
- Serve as a strategic partner to executive leadership on clinical utilization denial trends and appeal success rates.
- Recruit train mentor and evaluate a team of clinical appeal nurses and support staff.
- Establish performance metrics KPIs and accountability measures to drive team effectiveness and overturn rates.
- Foster a culture of collaboration clinical excellence and continuous improvement.
Qualifications
Education and Training: Bachelors or Associates degree in nursing preferred
Experience: Knowledge in the area of LTAC and IRF Criteria including: Medicare InterQual and Milliman are preferred. Currently licensed as an RN preferred.
Knowledge Skills and Abilities: Five years experience as a clinical nurse in an acute care addition having at least two years of experience in appeals case management discharge planning and/or utilization review is preferred.
About PAM Health
PAM HEALTH (PAM)based in Enola Pennsylvania provides specialty healthcare services through more than 80 locations as well as wound clinics and outpatient physical therapy locations in 17 states. PAM Health is committed to providing high-quality patient care and outstanding customer service coupled with the loyalty and dedication of highly trained staff to be the most trusted source for post-acute services in every community it serves. Its mission is to serve people by providing compassionate expert care and to support recovery through education and research. Joining our PAMily allows you to work in a collaborative environment with colleagues and leadership with exposure to a variety of patient care levels. Aside from our competitive pay generous paid benefit time and excellent insurance options you will also have opportunities for professional growth through our Education Advancement Program. We are excited to learn more about you and hope that you consider joining us on a shared mission to improve the lives of others by being an integral part of our We Care Program. Please take a moment to visit us online atfor a comprehensive look at how were able to positively impact our local communities.
PAM Health does not discriminate and does not permit discrimination including without limitation bullying abuse or harassment on the basis of actual or perceived race color religion national origin ancestry age gender physical or mental disability sexual orientation gender identity or expression or HIV status or based on association with another person on account of that persons actual or perceived race color religion national origin ancestry age gender physical or mental disability sexual orientation gender identity or expression or HIV status.
Required Experience:
Chief
Employment Type
Full-Time
