Director Pre Appeals Management-HSO Appeals Management Corporate 42nd Street-Full-Time-Days Remote

Director Pre Appeals Management-HSO Appeals Management -Corporate 42nd Street-Full-Time-Days -Remote

The Director Pre Appeals Management is a strategic enterprise leader who provides strategic leadership and operational oversight for the hospitals pre-appeals management program. This role ensures the appropriate use of medical resources compliance with regulatory standards and coordination of care to improve patient outcomes while controlling costs. The Director collaborates closely with medical staff vendors case management and payers to secure payment and benefits for beneficiaries that is in alignment with the clinical care provided.

• Lead and manage the pre appeals department and related vendors including supervision of pre appeals nurses and support staff.
• Develop and implement pre appeals strategies policies and procedures to ensure regulatory compliance (CMS The Joint Commission NCQA etc.).
• Oversee daily pre appeals activities including admission and continued stay and discharge reviews using CMS guidelines and payer contract terms.
• Ensure timely and appropriate communication with payers for authorization denials and appeals.
• Collaborate with physicians and clinical teams to ensure appropriate levels of care and efficient resource utilization.
• Analyze utilization data and key performance indicators to identify trends variances and opportunities for improvement.
• Serve as a liaison between hospital administration payers medical staff and external partners.
• Lead denial management and appeal processes to minimize revenue loss.
• Conduct staff education and training on denial avoidance processes documentation and compliance.
• Participate in hospital quality and performance improvement initiatives.
• Maintain current knowledge of healthcare regulations reimbursement models and best practices.
• Manage departmental budget staffing levels and performance evaluations.
  

Key Outcomes of Success:

• Enhanced patient satisfaction and financial transparency
• Measurable reduction in clinical submission errors and denied level of care.
• Alignment with organizational goals and regulatory requirements
• Demonstrated leadership in enterprise-wide initiatives that advance accessequity and financial stewardship

• Bachelors degree in Nursing (BSN) or related healthcare field required
• Masters degree in Nursing Healthcare Administration Business or related field strongly preferred
• Licensure/Certification:
  • Active RN license in the state of employment required
  • Certification in Case Management (CCM ACM) or Utilization Management preferred.
• 7 years of experience in clinical acute clinical utilization management appeals management or related operations
• 3 years in a leadership or management role
• Strong understanding of payer policies utilization management
  
• Skills & Competencies:
  • Proven ability to lead cross-functional teams and manage complex workflows
  • Strong analytical and problem-solving skills
  • Knowledge of relevant laws and regulations (e.g. HIPAA CMS utilization management standards)
  • Experience with EHR/EMR systems payer portals or access control tools
  • Excellent communication and interpersonal skills
• Preferred Qualifications (Industry-Specific):
  • Healthcare: Experience with utilization management for medical services procedures or medications
  • Insurance: Understanding of benefits verification coverage determination or claims workflows
  • Fintech/IT: EPIC

Non-Bargaining Unit 416 - HSO Appeals Management - MSH Mount Sinai Hospital